Respiratory System

RESPIRATORY
SYSTEM
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DEVELOPMENT OF RESPIRATORY SYSTEM 1
RESPIRATORY SYSTEM
CONTENTS
DEVELOPMENT OF RESPIRATORY SYSTEM ................................................................................................................... 5
ANATOMY OF RESPIRATORY SYSTEM ........................................................................................................................... 5
PHYSIOLOGY OF RESPIRATORY SYSTEM ........................................................................................................................ 6
GENERAL FEATURES OF RESPIRATORY PHYSIOLOGY ................................................................................................ 6
INSPIRATION AND EXPIRATION................................................................................................................................. 7
SURFACTANT ............................................................................................................................................................. 8
GASEOUS EXCHANGE ................................................................................................................................................ 8
VENTILATION PERFUSION RATIO AND COMPLIANCE ............................................................................................... 9
HYPERCARBIA AND ALVEOLAR HYPOVENTILATION ................................................................................................ 10
HYPERVENTILATION ................................................................................................................................................ 10
HIGH OXYGEN TENSION .......................................................................................................................................... 10
HYPOXIA .................................................................................................................................................................. 11
FEATURES OF HEMOGLOBIN ................................................................................................................................... 11
OXYHEMOGLOBIN DISSOCIATION CURVE ............................................................................................................... 12
REGULATION OF RESPIRATION ............................................................................................................................... 13
LUNG VOLUMES, CAPACITIES AND ALVEOLAR VENTILATION ................................................................................. 14
ACCLIMATISATION .................................................................................................................................................. 16
MOUNTAIN SICKNESS ............................................................................................................................................. 16
CAISSON’S DISEASE ................................................................................................................................................. 16
SIGNS AND SYMPTOMS OF RESPIRATORY SYSTEM .................................................................................................... 17
GENERAL SIGNS AND SYMPTOMS OF RESPIRATORY SYSTEM ................................................................................ 17
HEMOPTYSIS ........................................................................................................................................................... 18
CYANOSIS ................................................................................................................................................................ 18
CLUBBING................................................................................................................................................................ 19
PANCOAST TUMOR ................................................................................................................................................. 19
CAPLAN SYNDROME................................................................................................................................................ 19
PULMONARY EDEMA .............................................................................................................................................. 20
ARDS............................................................................................................................................................................ 20
PULMONARY EMBOLISM ............................................................................................................................................ 21
PULMONARY HYPERTENSION ..................................................................................................................................... 23
PULMONARY VENOUS HYPERTENSION ...................................................................................................................... 24
COR PULMONALE ........................................................................................................................................................ 24
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RESPIRATORY SYSTEM
RESPIRATORY FAILURE AND PULMONARY DISEASE ................................................................................................... 24

RESPIRATORY FAILURE ............................................................................................................................................ 24
EMPHYSEMA ........................................................................................................................................................... 25
OBSTRUCTIVE AND RESTRICTIVE LUNG DISEASE .................................................................................................... 26
RESPIRATORY CURVES ............................................................................................................................................ 27
BRONCHIAL ASTHMA .............................................................................................................................................. 27
MANAGEMENT OF ASTHMA ................................................................................................................................... 28
CHRONIC BRONCHITIS ............................................................................................................................................ 30
BRONCHIECTASIS .................................................................................................................................................... 30
INTERSTITIAL LUNG DISEASE ................................................................................................................................... 31
PNEUMOCONIOSIS.................................................................................................................................................. 32
OCCUPATIONAL LUNG DISEASE .............................................................................................................................. 32
ASBESTOSIS ............................................................................................................................................................. 33
SILICOSIS ................................................................................................................................................................. 33
PULMONARY HEMOSIDEROSIS ............................................................................................................................... 34
HYPERSENSITIVE PNEUMONITIS ............................................................................................................................. 34
EOSINOPHILIA ......................................................................................................................................................... 34
ASPERGILLOSIS ........................................................................................................................................................ 34
BRONCHIOLITIS ....................................................................................................................................................... 35
LARYNGOTRACHEOBRONCHITIS ............................................................................................................................. 35
BRONCHIAL FOREIGN BODY .................................................................................................................................... 36
BRONCHOSCOPY ..................................................................................................................................................... 37
SOLITARY NODULE .................................................................................................................................................. 37
PLEURAL EFFUSION, PNEUMOTHORAX AND MEDIASTINITIS ..................................................................................... 37
GENERAL FEATURES OF PLEURA ............................................................................................................................. 37
PLEURAL EFFUSION ................................................................................................................................................. 37
HEMOTHORAX ........................................................................................................................................................ 38
PNEUMOTHORAX .................................................................................................................................................... 39
LUNG SEQUESTRATION ........................................................................................................................................... 40
MEDIASTINUM ........................................................................................................................................................ 40
BRONCHOPLEURAL FISTULA ................................................................................................................................... 41
PNEUMONIA ............................................................................................................................................................... 41
GENERAL FEATURES OF PNEUMONIA ..................................................................................................................... 41
CAUSES OF PNEUMONIA......................................................................................................................................... 42
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RESPIRATORY SYSTEM
MORPHOLOGY OF PNEUMONIA ............................................................................................................................. 42

VIRAL PNEUMONIA ................................................................................................................................................. 42
STAPHYLOCOCCAL PNEUMONIA ............................................................................................................................. 42
STREPTOCOCCAL PNEUMONIA ............................................................................................................................... 43
ATYPICAL PNEUMONIA ........................................................................................................................................... 43
COMMUNITY ACQUIRED PNEUMONIA ................................................................................................................... 43
CMV PNEUMONIA ................................................................................................................................................... 44
LEGIONNAIRE’S PNEUMONIA ................................................................................................................................. 44
KLEBSIELLA PNEUMONIA ........................................................................................................................................ 44
PNEUMOCYSTIS CARNII PNEUMONIA ..................................................................................................................... 44
EMPYEMA ............................................................................................................................................................... 45
LUNG ABSCESS ........................................................................................................................................................ 45
BROCHIOLITIS OBLITERANS ..................................................................................................................................... 45
MANAGEMENT OF PNEUMONIA ............................................................................................................................ 46
TUBERCULOSIS ............................................................................................................................................................ 46
MYCOBACTERIUM TUBERCULOSIS ......................................................................................................................... 46
EPIDEMIOLOGY OF TUBERCULOSIS......................................................................................................................... 46
FEATURES OF TUBERCULOSIS ................................................................................................................................. 47
MORPHOLOGY OF TUBERCULOSIS .......................................................................................................................... 49
TUBERCULIN TEST ................................................................................................................................................... 49
SPUTUM EXAMINATION ......................................................................................................................................... 50
CULTURE OF MYCOBACTERIUM.............................................................................................................................. 50
DIAGNOSIS OF TUBERCULOSIS ................................................................................................................................ 51
TREATMENT OF TUBERCULOSIS .............................................................................................................................. 51
SARCOIDOSIS............................................................................................................................................................... 53
BRONCHOGENIC TUMORS .......................................................................................................................................... 54
GENERAL FEATURES OF BROCHOGENIC TUMOR .................................................................................................... 54
SMALL CELL CARCINOMA OF LUNG ........................................................................................................................ 55
NON SMALL CELL CARCINOMA OF LUNGS .............................................................................................................. 56
MANAGEMENT OF BRONCHOGENIC TUMOR ......................................................................................................... 57
BRONCHIAL ADENOMA AND BRONCHIAL CYST ...................................................................................................... 57
CYSTIC FIBROSIS .......................................................................................................................................................... 58
KARTAGENER SYNDROME ........................................................................................................................................... 58
VENTILATOR ................................................................................................................................................................ 59
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RESPIRATORY SYSTEM
KEY TO THIS DOCUMENT
Text in normal font – Must read point.

Asked in any previous medical entrance
examinations
Text in bold font – Point from Harrison’s

th
text book of internal medicine 18
edition
Text in italic font – Can be read if

you are thorough with above two.
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RESPIRATORY SYSTEM
DEVELOPMENT OF RESPIRATORY SYSTEM
Fetal respiratory movements 12 weeks

Respiratory bronchioles are formed Pseudoglandular stage of lung
during development
Common Lung anomalies Pulmonary hypoplasia, Foregut cysts, Pulmonary
sequestration
Bronchopulmonary dysplasia is seen with Prematurity, Barotrauma, Oxygen therapy
Long term complications of Small airway disease, decreased FRC,
bronchopulmonary dysplasia interstitial lung disease
Use of steroids in neonates is required in Bronchopulmonary dysplasia
ANATOMY OF RESPIRATORY SYSTEM
Respiratory cilia 9 microtubular doublet with central

singlets (9 + 2)
Number of rings in trachea 16 to 17 rings
Length of trachea 10 – 15 cm
Diameter of trachea 1.2 cm
Right hilum is Lower than left
Inferior most structure in right hilum Inferior pulmonary vein
Hilum of right lung is arched by Azygous vein
Mediastinal Surface of Right lung is associated with Superior vena cava
Hilum of left lung is arched by Arch of aorta
Uppermost structure in left lung hilum Pulmonary artery
Most cranial structure in root of left lung Pulmonary artery
Bronchopulmonary segment Surgically resectable, Named according to segmental
bronchus supplying it, It is drained by INTERsegmental
branch of pulmonary vein, Largest subdivision of a lobe,
First segment drains more than 1 pulmonary vein
Number of bronchopulmonary segments 10
in right lung
Number of bronchopulmonary segments 9
in left lung
Segment absent in left lung Medial basal segment
Eparterial bronchus is NOT present in Left lung
Parts of lower lobe of lung Superior, Medial basal, Posterior basal
NOT a part of lower lobe of lung Anteromedial basal
Lingual Left upper lobe
Pulmonary segments in middle lobe of right lung Medial, Lateral
In lungs, bronchial arteries supply bronchopulmonary Till respiratory bronchioles
tree
Bronchial arteries supply bronchopulmonary tree till Respiratory bronchioles
Blood supply of lungs Pulmonary artery, Pulmonary vein, Bronchial artery
Blood supply of Lungs Two bronchial veins on each side
Sensory supply of trachea Vagus
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PHYSIOLOGY OF RESPIRATORY SYSTEM 6
RESPIRATORY SYSTEM
Pulmonary plexus Cell bodies of post ganglionic

parasympathetic fibres
Normal diameter of Trachea 2 – 6 cm
Lining cells of alveoli Kulchitsky cells, Clara cells, Brush cells
NOT lining alveoli Langerhan cells
MC cells in bronchoalveolar lavage Macrophages
Clara cells are found in Terminal bronchioles
Clara cells in bronchoalveolar lavage seen in Bronchoalveolar carcinoma
Lepidic pattern Bronchoalveolar carcinoma
Variants of bronchoalveolar carcinoma Clara cell, mucinous, type II pneumocyte
Canals of Lembert in alveolar spaces in lung Bronchoalveolar connections, Prevent atelectasis, Delay
in collapse
th
Pleural reflection on left mid axillary line is in 10 intercostal space
Pleural extends up to which rib in mid axillary line 10
Pectus carinatum Pigeon chest
Pectus excavatum Funnel chest
Pectus excavatum Decrease in lung capacity, Cosmetic deformity,
Depression in chest
Pectus excavatum Inferior part of sternum depressed in
NOT true about pectus excavatum Gross CVS dysfunction
PHYSIOLOGY OF RESPIRATORY SYSTEM
GENERAL FEATURES OF RESPIRATORY PHYSIOLOGY
Normally lungs are kept dry by Osmotic pressure in interstitium

Normal intrapleural pressure -3 to -5 cm of H2O
Small airways have laminar flow because Extremely low velocity
Cough receptors is seen in Trachea
Type of receptors in bronchial smooth muscle Beta 2
Normal intrapleural pressure is negative because Chest wall and lung recoil in opposite direction
Negative intrapleural pressure is maintained by Absorption lymphatics
Negative intrapleural pressure is maintained by Lymphatic drainage of pleura
Intrapleural pressure is negative during both inspiration Thoracic cage and lung are elastic structure
and expiration because
Inflated state of lung in maintained by Negative intrapleural pressure
A person is having normal lung compliance and Slow and deep
increased airway resistance. Most economical way of
breathing
Effort during normal respiration is due to Lung elasticity
During inspiration, intrapleural pressure More negative
Airway obstruction if auscultation over trachea during Breath sounds more than 6 seconds
forced inspiration
Normal expiration At the end of normal expiration of air in lungs is ERV
Greatest proportion of airway resistance Mid stem bronchi
More resistance in expiration is due to Increased compression of airway
Increased airway resistance due to Forced expiration, Dense air, Low lung volume
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RESPIRATORY SYSTEM
Respiration stops in last stage of expiration, in forced Dynamic compression of airway

expiration because of
Neutral position of Chest End expiratory
Plateau pressure End expiratory pressure
Measurement of intravascular pressure by a pulmonary At end expiration
catheter should be done
Water fall effect in Middle lung
Blood flow to apex of lung during Systole
Flow volume curve in RS Extrathoracic obstruction
Child’s respiratory physiology differs from adult Smaller airways
because of
WRONG statement about Compliance Compliance is affected only by surfactant
Pulmonary circulation Hypoxia cause vasoconstriction, Blood volume in lung is
450 ml, Low resistance
Pulmonary circulation differ from systemic circulation Pulmonary vasoconstriction in hypoxia, Resistance low,
Capillary pressure low
Lung circulation V/P ratio is 0.8 at rest, In apex ventilation is less than
base
Pulmonary vascular resistance is Increase in cardiac output
decreased by
Bronchial circulation Contribute 2% of systemic circulation, NO gaseous
exchange, Causes venous admixing of blood, Provide
nutritive function to lung
Recruitment is seen in Lung
During heavy exercise, cardiac output increases up to Increase in number of wide open capillaries
five fold while pulmonary arterial pressure is very little.
Physiological ability of pulmonary circulation is best
explained by
Pulmonary circulation in hypoxia Vasoconstriction
Vascularity of lung Distended pulmonary veins in lower lobe
NOT true about lung circulation Decreased vital capacity in supine position, Most blood
in pulmonary capillary
Physiological dead space in lung Zone 1
Physiological dead space 150 ml
Normal ratio of physiological and anatomical dead 1:1
space
Anatomical dead space by Single breath nitrogen curve
Best known metabolic function of lung Conversion of angiotensin I to angiotensin II
Important non respiratory function of lung Sodium balance
INSPIRATION AND EXPIRATION
Lattisimus dorsi used in Forced EXPIRATION

Inspiratory muscles Diaphragm, external intercostal
Accessory muscles of inspiration Serratus anterior, Serratus posterior, Scalene
Muscle that does NOT contract during External intercostalis
forced expiration
Discharge spontaneously during quiet Inspiratory neuron
breathing
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RESPIRATORY SYSTEM
SURFACTANT
Surfactant is produced by Type II pneumocytes

Size and number of inclusions in type II Thyroxine
alveolar epithelial cells producing
surfactant is increased by
Accelerates maturation of surfactant in Glucocorticoid
lung
Surfactant production in lungs start at 28 weeks
Surfactant is made up of Phospholipid
Major constituent of Surfactant Dipalmityl Phosphotidyl Choline
Action of surfactant in human body is done by Lipid and protein
Hyaline membrane contains Fibrin
Functions of surfactant Increases compliance of lung, reduces
surface tension of alveolar fluid, prevents
collapse of alveoli
Mechanism of action of surfactant in alveoli Break the structure of water in alveoli
Pulmonary surfactant Maintains alveolar integrity
Stability of alveoli is maintained by Increase in alveolar surface area by surfactant
Stability of alveoli maintained by Reduced surface tension by surfactant
Blood air barrier Type II pneumocytes
GASEOUS EXCHANGE
Oxygen cascade Oxygen cascade describes the process of

declining oxygen tension from atmosphere
to mitochondria
In a normal healthy person, arterial 90%
oxygen is considered satisfactory if spO2 is
more than
When blood passes through systemic capillaries Increased protein content, Increased hematocrit,
Decreased Ph, Shift of hemoglobin dissociation curve to
right
PCO2 in atmospheric air 0.3 mm Hg
Alveolar CO2 40 mm Hg
Arterial carbon dioxide level 40 mm Hg
Least pCo2 Arterial blood
In alveolar gas, Mixed venous PCO2 is more than Alveolar PCO2
Movement of CO2 from pulmonary capillaries to alveoli Simple diffusion
CO2 diffuse more easily than O2 because More soluble in plasma
CO2 is primarily transported in blood as Bicarbonate
Percentage of O2 carried in chemical combination 97%
PaCO2 Alveolar gas equation, Barometric pressure = 760 mm
PAO2 = FiO2 ∗ PB − PH2O −
R Hg, Water vapor pressure = 47 mm Hg, Respiratory
quotient = 0.8
Alveolar gas pressure is equal to Body surface pressure
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RESPIRATORY SYSTEM
Po2 in atmospheric air

Partial pressure of O2 at atmospheric pressure of 760 160 mm Hg
mm Hg
Atmospheric pressure 760mm Hg. O2 = 21%, partial 159 mm Hg
pressure of 02?
Po2 In Alveoli 104 mm Hg
Normal value of PO2 in healthy man is 80 mm Hg
At attitude of 6500 m, atmospheric pressure is 347 mm 73 mm Hg
Hg. inspired pO2
pO2 in pulmonary capillary 97 mm Hg
pO2 of aorta 95 mm Hg (because of physiological shunt)
Partial pressure of oxygen in venous blood 4o mm Hg
Concentration of O2 in blood 0.0025 ml, atm 760 mm 80 mm Hg
Hg, approximate oxygen tension
Normal level of Oxygen in blood when hemoglobin is 20 ml/dl
saturated with O2
Arterial blood O2 in ml of O2 per dL 19.8
Amount of dissolved oxygen transported in 100 ml of 9 ml
plasma in a subject breathing 100% oxygen at 4 ATA
Additional amount of oxygen transported in 100 ml of 6 ml
blood in a subject breathing 100 % oxygen under
hyperbaric conditions of 4 ATA compared to
normobaric conditions (1 ATA)
If hemoglobin is completely absent, 83 L
amount of plasma for basal oxygen
requirement
Gas used to measure diffusion in lung CO
Fraction of inspired air in mouth to mouth respiration 0.16 (16%)
Respiratory quotient VCO2/VO2
Respiratory quotient of carbohydrate 1
Non Protein Respiratory Quotient 0.75
Rupture of mucosal blood vessels of trachea 40 mm Hg
Venous admixture by Thebesian veins, high V/Q areas of lung,
bronchial vein
VENTILATION PERFUSION RATIO AND COMPLIANCE
Normal respiratory system compliance 0.2 L/cm H2O

Specific lung compliance is decreased in Pulmonary congestion, Pulmonary fibrosis, Decreased
surfactant
Specific lung compliance is NOT decreased in Chronic bronchitis
Pulmonary ventilation PaO2 is maximum at apex
Ventilation perfusion ratio is maximum at Apex of lung
High oxygen tension in alveoli is due to Ventilation perfusion mismatch
Function of shunt Perfusion of non ventilated lung
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RESPIRATORY SYSTEM
HYPERCARBIA AND ALVEOLAR HYPOVENTILATION
Gradient of alvelolar arterial oxygen tension in Normal

Hypoventilation is
Gradient of alveolar arterial oxygen tension is increased Diffusion effect, Right to left shunt, Ventilation
in perfusion abnormality
Alveolar hypoventilation in Bulbar poliomyelitis, COPD, Kyphoscoliosis
Hypoventilation Excess of plasma bicarbonate in absence of volume
depletion
NOT associated with alveolar hypoventilation Lobar pneumonia
Management of hypoventilation NIPPV
Hypercarbia is characterized by Hypertension, Tachycardia, Mydriasis due to
sympathetic stimulation
CO2 retention is seen in Respiratory failure, Ventilator failure, Pulmonary
edema, Drowning
Apnoea is Cessation of respiration
Sleep apnoea, temporary pause for at least 10 seconds
HYPERVENTILATION
Hyperventilation caused by Decreased pH in CSF, decreased plasma HCO3,

increased adrenergic levels
Voluntary hyperventilation at rest is Washing out of CO2, alkalosis, convulsions,
associated with decrease in arterial CO2 pressure,
decreases H+ ion (increases pH)
NOT a cause of hyperventilation CO poisoning
Initial change after Hyperventilation Decreased PCo2 with Increased pH
In hyperventilation P50 decreases and O2 affinity increases
Reduction in arterial oxygen tension caused by Hypoventilation
Arterial blood gas determination in hyperventilation Reduced PCO2
shows
After hyperventilation for some time Lack of stimulation by CO2, anoxia can go
holding breath is dangerous, due to into dangerous level
Alveolar O2 tension is Increased by hyperventilation
Solubility of CO2 is 20 times than that of O2
HIGH OXYGEN TENSION
Hyperbaric oxygen is dangerous because it Is toxic to tissues

Toxic effects of high oxygen tension Pulmonary edema, Retinal damage, CNS excitation and
confusion
NOT an effect of high oxygen tension Hyperthermia
Decreased cerebral blood flow in high oxygen tension is Protective effect
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RESPIRATORY SYSTEM
HYPOXIA
O2 content of arterial blood 19.4 ml/100 ml

Decrease in respiration causes Decreased pH + Increased PCO2
Hypoxia When it is severe, it causes stimulation of sympathetic
nervous system, It leads to accumulation of hydrogen
and lactate ions, If it is chronic, causes rightward shift of
oxygen Hb curve.
Hypoxia is characterized by Intense chemoreceptor response, Low arterial
PO2,favourable response to 100 % CO2
Tachycardia in hypoxia is due to Diffuse vasodilatation
Hypoxia causes Decrease in cerebral blood flow
MC physiological cause of hypoxemia Hypoventilation
Most prone for hypoxic injury Hippocampus
Neurons may get irreversibly damaged if exposed to 8 minutes
significant hypoxia for
No stimulation of ventilation by hypoxia 60 mm Hg
until pO2 falls below
Hypoxia does NOT cause vasodilatation in Lung
Hypoxemia does NOT depend on Hb
Variant of hypoxia NOT stimulating peripheral Anemic hypoxia
chemoreceptors
Anemic hypoxia is due to Decreased O2 content in arterial blood
Best test for anemic hypoxia Oxygen content or Hb%
Hypoxia seen in general anesthesia Hypoxic hypoxia
Best parameter for analysis of hypoxic hypoxia Arterial pO2
Condition leading to tissue hypoxic without alteration of Cyanide poisoning
blood oxygen content
Stagnant hypoxia is due to Reduced blood flow
Best test for stagnant hypoxia AV difference
Histotoxic hypoxia CO and cyanide
Best test for histotoxic hypoxia AV difference of PO2 of venous blood
Oxygen therapy is NOT effective in Histotoxic anoxia
Does NOT used to prevent hypoxia Pin Index
Stimulus for pulmonary vasoconstriction Hypoxemia, Hypercapnia, Thromboxane
Pulmonary Vasoconstrictor Low PaO2
Primary pulmonary hypoventilation Does not respond to chemical stimuli
FEATURES OF HEMOGLOBIN
Hemoproteins Cytochrome c, Cytochrome 450, Myoglobin,

Hemoglobin, Catalase
Hemoprosthetic group is found in Myoglobin, Cytochrome oxidase
Heme synthesis require Ferrous ion, Glycine, Succinyl coA
Initially important for hemoglobin synthesis Glycine
First step of heme synthesis Glycine + Succinyl CoA
Key enzyme in heme biosynthesis ALA synthase
Hemoglobin is a buffer because of Histidine residue
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RESPIRATORY SYSTEM
Buffer NOT involved in non rapid achievement of Renal Hemoglobin

pH
Allosteric protein Hemoglobin
Quarternary Structure Hemoglobin
Hemoglobin is present in Hydrophobic pockets
Hemoglobin structure Hb has 4 polypeptide, Iron is present in ferrous state,
Hb is structurally similar to myoglobin, Ferrous ions are
in porphyrin rings
In hemoglobin, iron is bound to Histidine
In hemoglobin, the innate affinity of heme for carbon His E7
monoxide is diminished by presence of
Function of histidine E7 in hemoglobin Hindered environment, protects CO
poisoning
Fe++ is attached to Histidine F8 of globin chain
HbM Histidine F8 to tyrosine
HbF Histidine 21 to serine
HbS Glutamate for valine
Hb Sydney Valine for alanine
In lung R state favors Oxygenation (breaks salt bridge)
T structure is stabilized by 2,3 DPG
Decreased glycolytic activity impairs oxygen transport Decreased production of 2,3 bisphosphoglycerate
by hemoglobin due to
Embryonal hemoglobin Zeta epsilon
Type of hemoglobin with least affinity for 2,3-DPG HbF
ADT test for HbF
NOT true about fetal hemoglobin Strong affinity for 2,3 DPG
Hemoglobin unlike myoglobin shows Sigmoid curve of oxygen dissociation, Positive co
operativity
Feature common to both hemoglobin and myoglobin Heme at hydrophobic pockets
Each gram of hemoglobin carry 1.39 ml of O2
Carbon dioxide is carried in blood as Carbaminocompounds, dissolved gas,
bicarbonate
OXYHEMOGLOBIN DISSOCIATION CURVE
Amount of oxygen consumed per minute 250 ml

under basal condition
Oxyhemoglobin dissociated curve is S shaped
Oxyhemoglobin dissociation curve is sigmoid shaped Binding of one oxygen molecule increases the affinity of
because binding other O2 molecules
Oxygen dissociation curve is sigmoid in shape because Shifting affinity for Oxygen
of
Myoglobin dissociation curve Hyperbolic
Myoglobin is 8 alpha helix
Myoglobin does NOT use oxygen Because p50 is low
True about conversion of deoxy hemoglobin to Binding of O2 cause release of H+
oxyhemoglobin
Normal value of P50 on oxyhemoglobin dissociation 3.6 pKa
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RESPIRATORY SYSTEM
curve in an adult
During exercise, increase in O2 delivery to muscle Oxygen dissociation curve shifts to right, Increased
increase because of stroke volume, Increased extraction of oxygen from
blood, Increased blood flow to muscles
Role of 2,3-DPG Unloading oxygen to tissues
Major role of 2,3-DPG Release of oxygen
Feature of 2,3-DPG Higher concentration in adult blood
Increase in 2,3-DPG seen in Anemia, Hypoxia, Inosine
In anemia concentration of 2,3-DPG Increased
Fetal hemoglobin has higher affinity for oxygen due to Reduced 2,3 DPG concentration
Shift of Oxygen dissociation curve to right is by Temperature, pH, DPG concentration
Oxygen curve shift to right Decrease pH, increased temperature, increase in 2,3
DPG
Compound shifting curve to right 2,3 DPG
Shift to right in Hypercarbia, Sickle Hb
Acidosis shift curve to Right
Right shift in oxygen dissociation curve does NOT occur Transfusion
in
Oxygen dissociation curve does NOT shift to right in Blood transfusion, Metabolic alkalosis
Does NOT shift ODC to right Increased pH
Curve shift of left by Increased oxygen affinity of hemoglobin
Increased pH causes O2 dissociation curve to Left
What causes O2 curve to left Decreased temperature
Oxygen dissociation in peripheral tissues is NOT altered Anemia
by
Does NOT influence dissociation curve Chloride ion concentration
Oxygen affinity is increased by Alkalosis, Increased HbF, Hypothermia
Oxygen affinity is NOT increased by Hypoxia
Oxygen affinity is NOT increased in Hyperthermia
O2 delivery to tissue does NOT depend on Type of fluid administered
Decrease in affinity of hemoglobin when pH of blood Bohr Effect
falls
O2 delivery to tissue is decreased by Decreased hemoglobin level, Decreased PaO2,
Increased Ph
REGULATION OF RESPIRATION
Pacemaker of respiration Pre Botzinger complex

Spontaneous rhythmic respiration is initiated in Pre Botzinger complex
Rhythmic control of respiration lies at Dorsal respiratory centre
Rhythm of Respiration is maintained by Dorsal medulla
Most important stimulus of respiratory centre Decreased PaO2
Respiratory centre is stimulated by Hypercarbia
Respiratory centre Inhibited during swallowing
Respiratory centre depression NOT caused by Strychnine
Complete transaction of brain stem above Prevent any voluntary holding of breath
the pons
Section above pons inhibit Apneustic centre
Pneumotaxic centre Pons
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RESPIRATORY SYSTEM
Inhibition of Pneumotaxic centre causes Prolonged Inspiratory spasm

Lesion of pneumotaxic centre Deep gasping as if tidal volume is high
In cat apneustic centre is destroyed along with cutting Prolonged inspiratory spasm
of vagi
Lesion of prebotzinger complex Ondine curse (involuntary respiration is
affected)
Transection at mid pons level result in Apneusis
Transaction at mid pons level with intact Slow and deep breathing
vagii
Apneusis is caused by Parabrachial nucleus and vagus
What will be effect of respiration if transaction made Irregular and gasping
between pons and medulla
Lesion below medulla Total loss of respiration
NOT a stimulus for pulmonary vasoconstriction PGI2
Central chemoreceptors are most sensitive to Increased PCO2
Chemoreceptor reflex primarily causes Bradycardia, Vasoconstriction
Primary direct stimulus for excitation of central Increased H+
chemoreceptors
Central and peripheral chemoreceptors respond to Increased arterial CO2
Peripheral chemoreceptors stimulated by Hypoxia, Acidosis, Low perfusion pressure
Administration of pure O2 to hypoxic patients is Apnea occurs due to hypostimulation of peripheral
dangerous because chemoreceptors
Does NOT stimulate peripheral chemoreceptors Hypocapnia
Does NOT stimulate peripheral chemoreceptors Anemic hypoxia
Tidal volume excessive load is prevented by activation Bronchial stretch receptors
of
Inflation of lung induce further inflation Head’s paradoxical reflex
Herring Breuer inflation reflex Protective, involves pulmonary stretch
receptor, inhibition of inspiratory centre
Affect resting ventilation Stretch receptors, Oxygen, PCO2
Does NOT affect resting ventilation J receptor
J receptors are present in Pulmonary interstitium
Stimulation of J receptors cause Apnea followed by tachypnea
J receptor stimulation causes Apnea, hyperapnea, hypotension,
bradycardia
J receptor reflex A.S.Paintal (India)
J receptor reflex Sensitive to pulmonary congestion, Stimulated by
Bradykinin
Lung reflexes are mediated by Myelinated nerve fibres
LUNG VOLUMES, CAPACITIES AND ALVEOLAR VENTILATION
PFT Total lung volume increases in emphysema, Compliance

decreases in interstitial lung disease, Compliance is total
lung distensibility
Best indication of alveolar ventilation is provided by Tidal Volume
measurement of
Volume of air taken in and given out during normal Tidal volume
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RESPIRATORY SYSTEM
respiration
Tidal volume calculated by Inspiratory capacity minus inspiratory reserve volume
Tidal Volume in both Men and women 500 ml
Resting tidal ventilation 5 L/min
Minimal tidal volume for adult resuscitation 600 ml
Maintenance of tidal volume Bronchial stretch receptors
Expiratory reserve volume 1000 ml
Inspiratory reserve volume 3300 ml
Residual volume 1200 ml
Inspiratory capacity (TV + IRV) 3800 ml
Normal vital capacity (TV + IRV + ERV) 4800 ml
Functional residual capacity (ERV + RV) 2200 ml
Total lung capacity 6000 ml
Amount of air in lungs at the end of tidal breath FRC
Volume of air in Lungs when respiratory muscles are at Functional Residual capacity
rest
Functional residual capacity is Volume remaining of normal respiration
Functional residual capacity ERV + RV
Normal functional residual capacity 2.2 L
Functional residual capacity is measured following Normal expiration
At functional residual capacity, trans respiratory pressure Zero
system
Nitrogen washout method for Functional residual capacity
During quiet inspiration, alveolar 0 cm H2O
pressure
Alveolar ventilation (tidal volume – dead space volume) X respiratory rate
Total alveolar volume in litre per minute 4.2
Alveolar Ventilation if an adult shows tidal volume 600 6.75 L/min
ml, dead space of 150 ml and respiratory rate of 15/min
Alveolar PaO2 100 – 120 mm Hg
FEV1 Forced expiratory volume in first second
FEV1 is 80% of Vital capacity
Instrument used for measuring vital capacity and FEV Vitalograph
Vital Capacity TV+IRV+ERV
Critical Closing volume is Close to Residual Volume
Closing Capacity depends of Dependent Small Airways
Breathing reserve Maximum breathing capacity –
respiratory minute volume
Hyaline membrane disease FRC below closing volume
Decreased maximum mid expiratory flow rate indicates Small airway
obstruction in
Used to measure resistance to smaller airways Mid respiratory flow rate
Total lung capacity depends on Compliance of lung
Normal Vd/Vt ratio in adult 0.3
Better vision in video assisted thoracoscopic surgery Collapse of Ipsilateral Lung
created by
Spirometry used in diagnosis of Asthma
Volume that can NOT be measured by spirometer Functional Residual capacity
Spirometry does NOT measure Residual volume
Routine spirometry can NOT measure RV, FRC
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RESPIRATORY SYSTEM
In body plethysmography, a person is asked to expire Increase in lung and decrease in box
against closed glottis. change in pressure in the lung
and the box
Man connected to body plethysmograph for estimation inspired against closed glottis
of FRC
ACCLIMATISATION
During acclimatization Increase in minute ventilation, increased in sensitivity of

central chemoreceptors, increase in sensitivity of
carotid body to hypoxia
Features of acclimatization Polycythemia, increased diffusion
capacity of lung, increased pulmonary
ventilation, pulmonary vasoconstriction
Earliest change in high altitude Hyperventilation
pH and arterial pCO2 in a climber pH will rise and pCO2 will fall
(respiratory alkalosis)
Adaptation will be apt to increase the work capacity at Decreasing work load, increasing duration of exercise
high altitude
Mountaineer ascents 18000 feet in 2 days without Decreased barometric pressure, Decreased PaO2,
supplemental oxygen. Increased pH
Seen in high altitude climbers Hyperventilation, Decreased PaCO2, Pulmonary edema
Feature of pulmonary edema in high altitude climbers increased pulmonary capillary pressure, Normal left
atrial pressure
Compensating mechanisms involved in acclimatization Hyperventilation, Respiratory alkalosis
to altitude
A person goes to mountains, when he reaches about CO2 washout
5000 feet, he develops dyspnea.
Does NOT occur in High altitude acclimatization Increased Blood glucose
MOUNTAIN SICKNESS
Acute mountain sickness is associated with Sleep desaturation

Treatment of acute mountain sickness Acetazolamide
Monge’s disease Chronic mountain sickness
CAISSON’S DISEASE
For every 20 meter depth 3 atm pressure (1 atm due to atmosphere, 2 atm due to
water level)
Decompression sickness 1 in 10,000 divers
Decompression sickness seen in Diver, pilot
Caisson disease Gas embolism
Feature of Caisson disease Myonecrosis, paraplegia
Pathological changes in Caisson disease is due to N2
Main danger in deep sea divers is due to Oxygen and nitrogen
Nitrogen narcosis is due to Increased solubility of nitrogen in nerve cell membrane
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SIGNS AND SYMPTOMS OF RESPIRATORY SYSTEM 17
RESPIRATORY SYSTEM
SIGNS AND SYMPTOMS OF RESPIRATORY SYSTEM
GENERAL SIGNS AND SYMPTOMS OF RESPIRATORY SYSTEM
Hypoxemia Hypoventilation, Decreased FiO2, Myasthenia gravis,

Pulmonary emboli
MC fetal response to acute hypoxia Bradycardia
Platypnea Pleural effusion, Pulmonary embolism, Cirrhosis, COPD
Wheeze in children is caused by Foreign body, Bronchial asthma
Bilateral rhochi Pulmonary edema, Bronchiectasis, Emphysema
Rhonchi NOT in Pulmonary embolism
Vocal Resonance is increased in Consolidation
Vocal resonance is increases in Lobar pneumonia, localized fibrosis of lung, cavity in
apex
Cavernous respiration Cavity
Consolidation Trachea midline, Dull percussion note, Bronchial breath
sounds, Increased vocal resonance
Tubular breathing Consolidation
NOT a finding of consolidation Dullness
Homogenous opacification of right hemithorax with Collapse of right lung
right sided shift of mediastinum may be caused by
Golden S sign Right upper lobe collapse
Fever malaise, on examination tracheal shift to right Apical fibrosis
side, VR, VPL heard, percussion note dull
Emphysema COPD INCREASED static compliance. Decreased dynamic
compliance
Decreased static compliance ARDS, Pulmonary edema, Interstitial fibrosis, Fibrosing
alveolitis, Pulmonary congestion, Decreased surfactant
Wide Alveolar O2 gradient ARDS, Bronchiectasis, Intestinal fibrosis
Bronchial hyperplasia caused by Smoking, prematurity, allergy
Bronchial hyperplasia NOT caused by Theophylline
Lung granuloma with necrosis Tuberculosis, Histoplasmosis, Cryptococcosis, Wegener
granulomatis
Bull’s eye granuloma Pulmonary granuloma
Large granuloma is seen in Berylliosis, sarcoidosis
Bagassosis is most likely caused due to inhalation of Sugar cane
MC cause of secondary tracheomalacia Aberrant innominate artery
Sandstorm appearance on chest X ray Pulmonary alveolar microlithiasis
Diffuse parenchymal lung disease Activation of macrophages leads to laying
down of fibrous tissue and irreversible
lung scarring
Cause of pulmonary renal syndrome Leptospirosis, Hanta virus, Paraquat poisoning
Pulmonary renal syndrome is seen in Goodpasture syndrome, Leptospirosis, Hanta virus
infection, Wegener’s granulomatosis
APUD cells seen in Bronchial carcinoid
Vascular ring causing external airway compression can Angiography of aortic and pulmonary circulation
be diagnosed by
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RESPIRATORY SYSTEM
To visualize vascular sling causing tracheal or external MRI

airway compression which of the following would you
prefer
Pallor of creases of palm occurs with hemoglobin 10 gm/dl
Acute onset of cough, stridor and dyspnoea in children Foreign body, Asthma
Mutation in genes of surfactant protein B, Pulmonary alveolar proteinosis
GM –CSF, GM receptor is associated with
Disordered signaling of GM – CSF Primary alveolar proteinosis
Male newborn, chest X ray normal heart shadow, fine Neonatal alveolar proteinosis
reticulonodular infiltrates radiating from hilum, family
history reveals death of 2 children with similar clinical
scenario
Bat wing opacities in chest X ray Pulmonary alveolar proteinosis
Red Infarct is seen in Lung
Brown induration is seen in Lung
Thickening of pulmonary alveolar capillary membrane Pulmonary fibrosis
MC cause of amoebic lung abscess Direct spread from liver
Egg shell Calcification Silicosis, Sarcoidosis, Treated Lymphoma
Fleeting opacities on serial skiagram ABPA ,Wegener granulomatosis
Lymphangiomatosis of lung Pulmonary cyst of various sizes are seen
with increase in lung volume, may be
associated with tuberous sclerosis, may
cause recurrent pneumothorax, HRCT is
the investigation of choice
Diseases having predilection for upper Silicosis, later stages of sarcoidosis,
lobe eosinophilic granuloma
Diseases having predilection for lower lobe Idiopathic pulmonary fibrosis
HEMOPTYSIS
MC cause of Hemoptysis Bronchitis>Bronchogenic carcinoma

MC site of bleeding in hemoptysis Tracheobronchial tree
Hemoptysis is from Bronchial artery
Young man pulmonary tuberculosis, hemoptysis from Bronchial artery
Least likely cause of hemoptysis Empyema
Frank hemoptysis in ILD is NOT seen in BOOP
Massive hemoptysis >100 – 600 ml for a period of 24 hours
Recurrent hemoptysis, no abnormality on X ray. next Bronchoscopy
investigation
Ramussen aneurysm arise from Pulmonary artery
CYANOSIS
Central cyanosis Decreased arterial O2 saturation, hemoglobin abnormalities

Central cyanosis Chronic asthma, Alveolar hypoventilation,
Methemoglobinemia, Congestive pulmonary stenosis
Central cyanosis seen if O2 saturation < 85%
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RESPIRATORY SYSTEM
Central cyanosis is seen if O2 concentration <85%

MC cause of peripheral cyanosis Slowed circulation through skin
MC cause of peripheral cyanosis Normal vasoconstriction
Critical concentration of reduced Hb required to 4 (Harrison), 5 (Wintrobe)
produce cyanosis
Concentration of methemoglobin to appear cyanosis 1.5 g/dl
Cyanosis is not seen in Anemic Hypoxia
Cyanosis does NOT occur in severe anemia because of Critical concentration of Hb required to produce
cyanosis is reduced
Most subtle sign of vascular insufficiency Cyanosis
Cyanosis in trauma interpreted as Late sign of Hypoxia
Cyanosis can be an indication of Hypoxia
Cyanosis of cardiac or respiratory cause is Hypoxia test
detected by
Cyanosis NOT improving with 100% oxygen TOF
Severe hypoxemia without cyanosis occurs in CO poisoning, Anemia
CLUBBING
Earliest evidence of clubbing Fluctuation

Clubbing Primary biliary cirrhosis, Cryptogenic fibrosing alveolitis,
Central bronchiectasis
Unilateral clubbing Pancoast tumor, Aortic aneurysm, Branchial AV fistula
Clubbing of finger NOT seen in Acute pneumonia
PANCOAST TUMOR
Pancoast triad Shoulder or arm pain, atrophy of hand

muscles, Horner syndrome
50 year, smoker pain along left arm, ptosis, chest Pancoast tumor
radiograph soft tissue opacity at left lung apex with
destruction of adjacent ribs
Pancoast tumor seen with Cancer apical lobe of lung
Superficial sulcus tumor of lung presents with Pancoast syndrome
Pancoast tumors are commonly Squamous cell carcinoma
Features of Pancoast tumor Ptosis, Miosis, Loss of Ciliospinal reflex
Pancoast tumor is usually Unilateral
Patient with Pancoast tumor develops loss of voice after Involvement of recurrent laryngeal nerve
radiation
NOT seen in pancoast tumor Hemoptysis
NOT true of Pancoast tumor Excessive sweating
NOT seen in pancoast syndrome Myasthenia gravis
CAPLAN SYNDROME
Cavitating lesions of lung Caplan syndrome, Wegener granulomatosis, Squamous

cell carcinoma
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ARDS 20
RESPIRATORY SYSTEM
45 year old coalmine worker, Cutaneous nodules, joint Caplan syndrome

pain, occasional cough, dyspnoea, multiple small
nodules in bilateral lung fields, some nodules show
cavitation and specks of calcification
PULMONARY EDEMA
Adaptations that will be apt to increase the work Decrease workload and decreasing duration of exercise
capacity at high altitude
Acute pulmonary edema in high altitude Increased capillary pressure in affected
is because of areas of lung
High altitude pulmonary edema Associated with pulmonary vasoconstriction,
Exacerbated by exercise, Occurs both in acclimatized
and unacclimatized individual, Associated with high
cardiac output
High altitude pulmonary edema Associated with pulmonary hypertension
Normal PCWP with pulmonary edema is seen in High altitude, cocaine overdose, narcotic overdose, post
cardiopulmonary bye pass
High altitude pulmonary edema Simulate pneumonic consolidation on chest X ray
Management of high altitude pulmonary edema Nifedipine, hyperbaric therapy (if descent is not possible)
Management of high altitude cerebral edema Dexamethasone, hyperbaric therapy (if descent is not
possible)
Contraindications to hyperbaric therapy Pneumothorax, bleomycin
Minimum pressure in Left atrium for development of 30 mm Hg
Pulmonary edema
Kerley B lines are seen in Pulmonary edema
Uremic lung commonly results due to Pulmonary edema
Unilateral pulmonary edema Aspiration pneumonitis, post pleural aspiration,
lymphoma
Frothy copious blood tinged sputum Acute pulmonary edema
Batwing distribution of alveolar edema fluid Low pressure pulmonary edema
Kerley A and Kerley B lines are seen in Early pulmonary edema
Used in pulmonary edema Frusemide
Morphine is NOT contraindicated in Acute Pulmonary Edema
NOT given for acute onset of breathlessness cough and Morphine
fever in children
Drug NOT used in management of severe pulmonary Thiazide
edema
NOT an initial management of acute life threatening Digoxin
cardiogenic pulmonary edema
ARDS
Acute lung injury PaO2/FiO2 less than or equal to 300 mm Hg

ARDS PaO2/FiO2 less than or equal to 200 mm Hg, exudative
phase (first 7 days), proliferative (7 – 21 days), fibrotic (3 –
4 weeks)
MC cause of ARDS Sepsis
Shock lung ARDS
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PULMONARY EMBOLISM 21
RESPIRATORY SYSTEM
Acute lung injury Aspiration, Toxic gas inhalation, Lung contusion

Acute lung injury NOT caused by Cardiopulmonary bypass with heart lung machine
ARDS is seen in Pulmonary edema, hypoxemia, stiff lung
MC abnormality associated with ARDS Hypoxemia
Pathology in ARDS Diffuse Alveolar hemorrhage
Feature of shock lung Diffuse alveolar damage
ARDS affects Type 2 pneumocyte
ARDS associated with Acute pancreatitis, Trauma, Severe falciparum malaria
Features of acute lung injury Bilateral interstitial infiltrates, PCWP < 18 mm Hg,
Normal left atrial pressure, PaO2/FiO2 < 300 mm Hg
ARDS PaO2/FiO2 < 200 mm Hg
ARDS Type I Respiratory failure,PaO2/FiO2 < 200 mm Hg PaO2
< 50 mm Hg, PCWP <18 mm Hg
ARDS Decreased pulmonary compliance, Increased pulmonary
artery pressure, Severe hypoxemia, Pulmonary shunting
First sign of ARDS Tachycardia
Histopathology of ARDS Waxy eosinophilic membrane in alveolar
wall
NOT seen in ARDS Hypercapnia, Increased left atrial pressure
PULMONARY EMBOLISM
Risk factors for pulmonary embolism OCP, Pregnancy, Leg paralysis, Behcet’s disease
Does NOT predispose to pulmonary embolism Progesterone therapy
Postoperative pulmonary embolism is NOT associated Tall and thin man
with
NOT predispose to pulmonary embolism Progesterone therapy
Commonest cause of pulmonary embolism Thrombosis of leg veins
MC cause of pulmonary embolism Right heart failure
MC cause of paradoxical embolism Isolated calf vein thrombosis
Commonest site of lodgement of pulmonary embolus Left upper lobe
MC Site of Pulmonary Embolism in DVT Femoral Vein
Pulmonary emboli 60-80 % emboli are clinically silent, More than 95%
venous emboli originate from deep leg veins, Embolic
obstruction of medium sized vessels may result in
pulmonary infarction
Feature of pulmonary embolism Isolated raised pulmonary embolism
Massive pulmonary embolism Breathlessness and syncope, central and peripheral
cyanosis, elevated JVP and heart rate
Pulmonary embolism may present with Isolated raised respiratory rate
MC cause of preventable hospitable death Acute pulmonary embolism
MC cause of death within 3 months after Total Hip Pulmonary thromboembolism
Replacement
MC cause of Acute Cor Pulmonale Pulmonary Embolism
MC cause of acute RVF Massive pulmonary embolism
Both exudative and transudative Pleural effusion is seen Pulmonary embolism
in
End Tidal CO2 decreased during surgery Pulmonary Embolism
Focal wedge shaped firm area accompanied by Lung with pulmonary thromboembolism
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PULMONARY EMBOLISM 22
RESPIRATORY SYSTEM
extensive hemorrhage with red appearance. lesion has

base on the surface of organ
Patient with fracture pelvis admitted in ICU, sudden Pulmonary thromboembolism
dyspnoea and chest pain
MC symptom of Pulmonary Embolism Dyspnea
Sequence of symptoms in pulmonary embolism Dyspnea, pain, hemoptysis
Classic triad of Chest pain, Hemoptysis, dyspnea in Only 10 - 20% of cases
Pulmonary embolism
Receptors stimulated by Acute Pulmonary emboli J receptors
MC ECG abnormality in Pulmonary Embolism Sinus tachycardia
Hampton’s hump in chest X ray Pulmonary embolism
Chest X ray finding in pulmonary embolism Westermark sign (Focal oligemia)
S1Q3T3 sign Pulmonary embolism
Palla’s sign Enlarged descending pulmonary artery
Knuckle sign Pulmonary embolism
Echo finding in pulmonary embolism McConnel sign
Sudden cardiopulmonary collapse in pulmonary 60% of pulmonary circulation obstructed by emboli
embolism is due to
Percentage of pulmonary emboli that proceed to 5-15%
infarction
NOT seen in pulmonary embolism Bradycardia
NOT suggestive of Pulmonary embolism Wheeze
Girl child, fever cough, dyspnoea, right lower lobe CT scan of chest
patchy consolidation. Treatment was given. After 8
weeks symptom improved, but X ray show dense
consolidation involving whole of right lower lobe. next
best line of management
IOC Pulmonary embolism CT san
Most important investigation for Pulmonary embolism CT angiography
Best Initial imaging for Pulmonary Embolism Pulmonary Angiography
Best investigation when suspicion of pulmonary Multidetector CT angiography
embolism
Investigation of choice in pulmonary embolism Ventilation perfusion scan
55 year old man who has been in bed rest for past 10 Ventilation perfusion scan
days, complaints of breathlessness and chest pain, CXR
normal. next step in investigation
In pulmonary embolism, finding in perfusion scan Perfusion segmental defect, Perfusion defect with
normal lung scan and radiography
D dimer most sensitive diagnostic test for Pulmonary embolism
Sensitivity of d-dimers in Pulmonary embolism 95%
False positive increase in d-dimer MI, pneumonia, pregnancy
D-dimer decrease in Anticoagulant therapy
Pulmonary embolism best diagnosed by Radionucleides
Young patient presenting with acute pulmonary Thrombolytic therapy
embolism, BP normal, ECHO reveals right ventricular
hypokinesia, compromised cardiac output
LMWH for venous thromboembolism Enoxaparin, Dalteparin
Fondaparinux Anti Xa pentasaccharide
Anticoagulants are contraindicated in Neurosurgery (intermittent pneumatic compression device
can be used)
In pulmonary embolism, fibrinolytic therapy is Risk of embolism
responsible for
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PULMONARY HYPERTENSION 23
RESPIRATORY SYSTEM
IVC filter NOT used for Negligible size thrombi
PULMONARY HYPERTENSION
Normal pulmonary artery pressure at rest Systolic 25 mm Hg, diastolic 10 mm Hg

Normal pulmonary mean arterial 15 mm Hg
pressure
Normal pulmonary capillary pressure 10 mm Hg
Fall in Pulmonary blood volume does NOT occur in Left Ventricular failure
Basic morphology in primary pulmonary hypertension Bone morphogenic protein receptor II
Causes of pulmonary hypertension Morbid obesity, high altitude, fenfluramine
Pulmonary hypertension may occur in Toxic oil syndrome, progressive systemic sclerosis,
sickle cell anemia
NOT a cause of pulmonary hypertension Hyperventilation, argemone mexicana poisoning
Reduced exercise tolerance, drop in oxygen saturation Primary pulmonary hypertension
from 92% to 86% on exercise with a normal FVC and
FEV1/FVC is consistent with diagnosis of
Isolated reduction in DLCO with nearly normal flow Primary pulmonary hypertension
volumes FVC and FEV1/FVC in a young female with
progressive dyspnoea
Closed fixed splitting of S2 Pulmonary hypertension
Pre capillary pulmonary hypertension Increased capillary pressure, Right ventricular
hypertrophy, Increased pressure in pulmonary
circulation
Pre capillary vessels in pulmonary circulation is Thin walled
Pre capillary pulmonary hypertension Pulmonary vasculitis, Primary pulmonary hypertension,
Thromboembolism
Post capillary pulmonary hypertension Mitral stenosis
Irreversible finding of Pulmonary Hypertension Plexiform
Changes in pulmonary hypertension Main pulmonary artery to arterioles
Pulmonary hypertension in COPD is due to Hypoxia, Pulmonary vasoconstriction, High lung volume
Jug Handle Appearance Primary Pulmonary Hypertension
Pruning of pulmonary arteries Pulmonary hypertension
W sign Eisenmenger syndrome
W sign on ECHO Pulmonary hypertension
Primary Pulmonary Hypertension – First Line Calcium Channel blocker
Treatment of Primary pulmonary hypertension PGI2
Iloprost Prostacyclin analogue
Sildenafil PDE 5 inhibitors
Primary Pulmonary Hypertension in Newborn Tolazoline
Inhaled nitric acid used for reducing Pulmonary hypertension
Drug used in management of Primary pulmonary Bosentan
hypertension
Bosentan is Endothelin receptor antagonist
Most powerful vasoconstrictor in the body Endothelin
Endothelin 1 Bronchoconstrictor, Vasoconstrictor, Decreased, GFR,
Inotropic effect
Endothelin I 39 aminoacid prohormone, act in
paracrine fashion, regulates pulmonary
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PULMONARY VENOUS HYPERTENSION 24
RESPIRATORY SYSTEM
blood flow
Endothelin II Vasoconstriction, bronchoconstriction, decreased GFR,
inotropic receptor
Pulmonary artery pressure is decreased Nitric oxide
by
NOT a therapeutic use of prostaglandin E1 Primary pulmonary hypertension
NOT used in treatment of pulmonary hypertension Alpha blockers
NOT used in treatment of pulmonary hypertension Beta blockers
PULMONARY VENOUS HYPERTENSION
Perihilar fluffy opacities of chest wall, Peribronchial Pulmonary venous hypertension

cuffing, Upper lobar diversion, Pulmonary ossicles and
fine nodular pattern
Kerley B lines Pulmonary venous hypertension
Earliest radiological sign of pulmonary venous Cephalization of pulmonary vascularity
hypertension in chest X ray
NOT a feature of pulmonary venous hypertension Uniformly branching lines parallel to pleura
COR PULMONALE
MC cause of Chronic Cor Pulmonale COPD

Causes of chronic cor pulmonale COPD, cystic fibrosis, primary pulmonary hypertension
Causes of chronic cor pulmonale Recurrent pulmonary embolism,
kyphoscoliosis
Features of chronic cor pulmonale Kerley B line, Pleural effusion, cardiomegaly
NOT a radiological feature of chronic cor pulmonale Prominent lower lobe vessels
RESPIRATORY FAILURE AND PULMONARY DISEASE
RESPIRATORY FAILURE
MC cause of type I respiratory failure Chronic bronchitis with emphysema

Type I respiratory failure associated with ARDS
NOT true about Type I respiratory failure Increased Pco2
False about type I respiratory failure Normal A-a gradient
Type II respiratory failure Low pO2, High PCO2
NOT a cause of type II respiratory failure Foreign body causing obstruction
Post operative respiratory failure Type III
Type III respiratory failure Lung atelectasis
Type IV respiratory failure Hypoperfusion of respiratory muscles in shock
Bilateral diaphragmatic paralysis HYPERCAPNEIC failure, Sniff test positive,
Diaphragmatic pacing is useful if any nerve is intact
Pulmonary compliance NOT decreased in COPD
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RESPIRATORY FAILURE AND PULMONARY DISEASE 25
RESPIRATORY SYSTEM
Chronic respiratory failure eventually Pulmonary hypertension, right sided

develop into heart failure
MC indication for lung transplantation COPD, IPF
Bilateral lung transplantation is indicated in Cystic fibrosis
Bode index for Lung transplantation
EMPHYSEMA
MC organism causing Emphysema in children under 2 Staphylococcus

years
MC Type of Emphysema clinically Centriacinar
MC Type of Emphysema histologically Irregular
MC type of Emphysema Centriacinar
Predominant emphysema Pink puffer
Emphysema Breathlessness is characteristic presenting symptom,
Diffusion rate of carbon monoxide is reduced, Long
term bronchodilator therapy do not improve lung
function
Emphysema Decreased vital capacity, Increased total lung capacity,
Decreased FEV1, Decreased FEV1/FVC ratio
Emphysema INCREASED intercostals space, Low flat diaphragm-
terrace pattern, Tubular pattern, Increased
radioluscence
Tubular Heart Emphysema
Cause of Lower airway obstruction in Emphysema Loss of Elastic Recoiling
Hypoxemia in emphysema is due to Destruction of alveoli, physiological dead space, elastic
recoil
Deficiency of α1-antitrypsin is indicated in pathogenesis Emphysema
of
Emphysema with cirrhosis is seen in α1-antitrypsin deficiency
Centiacinar emphysema is seen in Smoking
Alpha 1 antitrypsin deficiency is associated with Panacinar emphysema
Emphysema seen in smoker with chronic bronchitis Centrilobular
Congenital lobar emphysema is commonly Left upper lobe
seen in
Hyperinflation of lung in Chest X ray Congenital lobar emphysema
Investigation of choice for congenital Helical CT
lobar emphysema
Lung volume reduction operations are Emphysema
used in management of
Interstitial emphysema Chest injury, Tracheostomy, Surgical wound
Hamman sign Mediastinal emphysema (pneumomediastinum)
Continuous diaphragm sign Pneumomediastinum
Pulmonary function changes seen in emphysema Increased total lung capacity
Total Lung capacity in COPD Normal
Vital capacity in COPD Increased
Barrel chest is seen in COPD
GOLD criteria for COPD
Best investigation to measure lung volume in Body plethysmography
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RESPIRATORY SYSTEM
emphysematous lesion with bullous lesion

Compliance of lung is NOT decreased in Emphysema
Clubbing NOT seen in Emphysema
Macleod syndrome Not a true emphysema, Occurs before 8 years of age,
Unilateral emphysema, Swyer James syndrome
Macleod/Swyer James Syndrome Not True Emphysema
Alpha 1 antitrypsin is synthesized in Liver
Alpha 1 antitrypsin deficiency cause Neonatal hepatitis
Alpha 1 antitrypsin deficiency associated with Panacinar emphysema, Pulmonary emphysema,
Diastase resistant hepatic cells, Fibrosis of portal tract
Alpha 1 antitrypsin deficiency PAS +ve diastase resistant globule
Metabolic disorder in children NOT amenable to Alpha 1 antitrypsin deficiency
treatment
OBSTRUCTIVE AND RESTRICTIVE LUNG DISEASE
Normal value of FEV1 in adult male 80 %

Normal FEV1/FVC Greater than 0.8
Decreased mid expiratory flow rate indicates Small airways
obstruction in
When localized deficiencies of perfusion Obstructive airway disease
can be matched with deficiencies of
ventilation with normal X ray
Obstructive lung disease RV increased, Decreased maximum breathing capacity,
Decreased FEV, Decreased vital capacity
Finding in Obstructive Lung disease Residual Volume Increases, FEV1/FVC Decrease
Chronic obstructive lung disease Decreased FEV1,increased RV, decreased diffusion
capacity
Obstructive Lung Disease Decrease in Expiratory flow rate, RV Increase,FEV1,FVC
Decreased
Increased in obstructive lung disease and TLC, RV, FRC
decreased in restrictive lung disease
FEV/FVC decreased in (less than 0.8) Obstructive lung disease
Changes in upper airway obstruction Gall bladder contraction, pancreatic enzyme secretion,
decreased lower esophageal sphincter
FEV1/FVC decreased in Asthma
Restrictive Lung Disease Decrease in Lung Volumes, Decrease in
VC,TLC,Compliance,FEV1/FVC Normal/Increased
Profile of Restrictive Lung disease Increased FEV1/FVC and decreased compliance
Abnormal preoperative pulmonary function test in a Increased RV/TLC
patient with severe kyphoscoliosis
NOT decreased in restrictive lung disease Alveolar arterial difference in PaO2
NOT an abnormality in restrictive lung disease Reduced FEV1/FVC ratio
Normal timed vital capacity, decreased total vital Scoliosis
capacity
Kyphoscoliosis Restrictive lung disease, Decreased RV and decreased
TLC
Decreased vital capacity and decreased total lung Sarcoidosis, Restrictive lung disease
volume
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RESPIRATORY SYSTEM
Scleroderma associated with Restrictive lung disease, Interstitial lung disease

Diffusion capacity Normal in obstructive lung disease, Decreased in
restrictive lung disease
Gas used to measure diffusion capacity of lung CO
DLCO in chronic bronchitis Normal
Elevated DLCO -carbon monoxide diffusion capacity Alveolar hemorrhage, Goodpasture syndrome
Diffusion capacity of lung decreased in DLCO Interstitial lung disease, emphysema, primary
pulmonary hypertension
In Pink puffers later stages, DLCO will be Decreased
DLCO decreased in Emphysema, primary pulmonary hypertension,
infiltrative lung disease, interstitial lung disease,
pulmonary embolism
RESPIRATORY CURVES
Normal curve
Obstruction of airflow
Fixed central obstuction
BRONCHIAL ASTHMA
Number of genes associated with asthma More than 100

IL 4 cluster on Chromosome 5
Asthma is associated with ADAM 3
Chemicals associated with asthma Toluene diisocyanate, trimellitic anhydride
Drugs that can precipitate acute attack of asthma Phenylbutazone, Naproxen, Aspirin
Most predictive and dangerous side effect of Acute asthmatic attack
proponolol
Intrinsic asthma Normal IgE levels, Increasing incidence, Allergic asthma
common in young, Idiosyncratic asthma common in
elderly, Idiosyncratic asthma aka intrinsic asthma, Nasal
polyp, NOT allergic, NO family history
Prominent feature of Extrinsic asthma Increase in IgE cells
Cough in asthma Episodic wheezing, hyper reactive airway, persistent
cough
Bronchial asthma is associated with raised levels of Leukotrienes
Asthmatic wheeze Tropical eosinophilia, Loeffler’s syndrome
Asthmatic patient in affluent countries allergic to Dermatophagoides pteronyssinus
Universal finding in asthma Hypoxia
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RESPIRATORY SYSTEM
Mechanism of hypoxemia in asthma Ventilation perfusion mismatch

Atopy is associated with Bronchial asthma
Silent chest is observed in Bronchial asthma
Bronchial asthma Small and large airways are involved
Bronchial asthma with silent chest Grave prognosis
Features of acute severe asthma Tachycardia , PEFR < 50%,respiratory acidosis, increased
pulsus paradoxus
Aspirin sensitive asthma associated with Nasal polyp
Late response in bronchial asthma is due to Eosinophils
Features of steroid resistant asthma Failure to respond to oral prednisolone 40
mg OD for 2 weeks
Child with 2 attacks during night and 3 attacks during Moderate persistent asthma
daytime in a week is grade
NOT an indication of ICU admission of Bronchial asthma Prolonged wheeze
NOT a feature of bronchial asthma Airway responsiveness
NOT true of childhood asthma Absence of Wheezing after exercise
NOT true about asthma Necrosis of airway
Creola Bodies Asthma
Whorled epithelium in asthma Curschman spiral
Sputum of Bronchial asthma Charcot Leyen Crystals (Eosinophilic granules)
Bronchial asthma is characterized by Decreased FEV1, Decreased Vital capacity
In asthma, parameter showing greater improvement on FVC
inhaling bronchodilator
Bronchial asthma is definitely diagnosed by Reversible responsiveness of bronchial musculature
Size of droplet of drug for humidification to be used in <5 micron
nebuliser
Best route of administration to treat a steroid Inhalation
dependent asthmatic is by
Inhibition of 5 lipoxygenase is useful in Bronchial asthma
3 year boy, progressive shortness of breath for 1 day, Administer 100% oxygen by mask
history of bronchial asthma, blue, gasping,
unresponsive. first done
MANAGEMENT OF ASTHMA
Criteria for reversibility in bronchial Increase in FEV1 of >12% or 200 ml after 15

asthma minutes of inhaled beta 2 agonist or after
2 to 4 weeks of prednisolone therapy
Test to differentiate between bronchial Methacholine challenge test (test is
asthma and COPD contraindicated if the patient is
symptomatic)
PFT in exercise induced asthma Normal
Marker of airway inflammation in FENO (exhaled NO)
allergy associated asthma
Non invasive test to measure eosinophilic airway Exhaled NO
inflammation
Useful in acute asthma Terbutaline
Used in bronchial asthma Beta 2 agonist
Given subcutaneously Terbutaline
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RESPIRATORY SYSTEM
NOT a recognized action of terbutaline Diuretic effect

Acute Asthma Salbutamol
Salbutamol is preferred over adrenaline in asthmatic Beta 2 selectivity
due to
Most unpleasant side effect of salbutamol Tremor
NOT a side effect of salbutamol Sedation
NOT an adverse effect of salbutamol Hypoglycemia
MC mode of treatment of 1 year old child with asthma Inhaled short acting beta 2 agonist
Beta blockers used in bronchial asthma Selective beta 2 agonism
Long acting sympathomimetics used in bronchial Salmeterol
asthma
Long acting β2 agonist Salmeterol
Adverse effect of beta 2 agonist Hypokalemia, Hyperglycemia
Adverse effect of Salmeterol Tachycardia
NOT associated with treatment with beta 2 agonist Hyperkalemia
Theophylline Dose REDUCED in cardiopulmonary disease, Increase in
dose required in smokers, Inhibits phophodiesterase,
Increased cAMP
Mechanism of action of theophylline Phosphodiesterase inhibition, adenosine receptor
antagonism, increased histamine deacetylation
Mechanism of action of theophylline on bronchial Phosphodiesterase 4 inhibition
asthma
Theophylline activates Histone deacetylase 2
Theophylline has antagonistic interaction with Adenosine receptor
Theophylline Inhibition of Phosphodiesterase
Theophylline Potent Vasodilator
Effect of theophylline on insulin Increases insulin
Drug increases the level of theophylline Ciprofloxacin, Cimetidine, Allopurinol
Interaction of theophylline with ciprofloxacin Ciprofloxacin decreases theophylline metabolism
Drug inhibiting theophylline metabolism Ciprofloxacin
In a patient of chronic asthma on treatment with Erythromycin
theophylline, NOT used to treat his upper respiratory
tract infection
Do NOT affect metabolism of theophylline Steroids
Theophylline overdose causes Seizures
Drug used in bronchial asthma needs monitoring Theophylline
Therapeutic blood range of theophylline in microgram 5-20
per milliliter
Drug of choice in theophylline poisoning Propanolol
(Methylxanthine)
Loading dose of aminophylline 5-6 mg/Kg
Enzyme inhibited by aminophylline Phosphodiesterase
Rapid infusion of intravenous aminophylline may cause Convulsions
Inhibition of 5-LOX used in Bronchial asthma
Treatment of Exercise induced asthma Prophylactic steroid
Soft steroid used in bronchial asthma Cicelsonide
Anti inflammatory medication Fluticasone, budesonide
Inflammation of airway reduced by Fluticasone, Budesonide
Complications of aerosol steroids Oral candidiasis
NOT a bronchodilator but useful in asthma Beclomethasone
Tiotropium is used for Treating asthma
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RESPIRATORY SYSTEM
Drug of choice in asthma associated with heart disease Ipratropium bromide

Ipratropium bromide used in bronchial asthma is Anticholinergics
Anti asthmatic NOT indicated by oral route in pregnancy Ipratropium bromide
Disodium cromoglycate is used as Inhalational route
Drug of choice In exercise induced asthma Sodium cromoglycate
Drug NOT used in acute severe asthma Sodium cromoglycate
Release of histamine and leukotrienes from mast cells is Nedocromil sodium
prevented by
Montelukast Leukotriene antagonist
Mechanism of action of Montelukast Inhibition of leukotriene production
NOT used in acute asthma Montelukast
Leukotriene receptor antagonist used for bronchial Zafirlukast
asthma
Zafirlukast Inhibit lipoxygenase pathway, Blocks LT receptor, Can
be administered orally
Leukotriene receptor antagonist used in bronchial Zafirlukast
asthma
Found to be useful in acute severe asthma Magnesium sulphate
New drug in treatment of bronchial asthma Omalizumab
Route of administration of omalizumab Subcutaneous
Treatment of brittle asthma (refractory) Epinephrine
Treatment of nocturnal asthma Hydrocortisone
NOT a preventive therapy of nocturnal Salmeterol
asthma
Drug of choice in status asthmaticus IV diazepam
Drug contraindicated in Status asthmaticus Morphine
Drug contraindicated in bronchial asthma Propanolol
Drug NOT used in Bronchial asthma Phenylephrine
Cough suppressant Pholcodeine
Directly acting cough suppressant Dextromethorphan
Dextromethorphan is used as Anti tussive
Dextromethorphan differs from codeine in No constipation
CHRONIC BRONCHITIS
Increased Reid index Chronic bronchitis

Ratio of Mucous gland thickness to thickness of wall Reid index normal 0.4
between epithelium and cartilage
BRONCHIECTASIS
Smoking is NOT associated with Bronchiectasis

NOT premalignant at the same site Bronchiectasis
Anderson triad Bronchiectasis, cystic fibrosis, vitamin A
deficiency
Definition of massive hemoptysis More than 600 ml per 24 hours
MC cause of Massive Hemoptysis Bronchiectasis
Congenital causes of bronchiectasis Mounier Kuhn syndrome (Tracheobronchomegaly), William
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RESPIRATORY SYSTEM
Campbell syndrome
Abnormal permanent dilatation of bronchi and Bronchiectasis
bronchioles
MC type of bronchiectasis Cylindrical/tubular
Traction bronchiectasis is due to Fibrosis
Proximal or central bronchiectasis is ABPA
associated with
Bronchiectasis common in Left lower lobe
Appearances associated with bronchiectasis Tram track, signet ring, tree in bud
Pseudobronchiectasis Atelectasis
Absorptive atelectasis is due to Obstruction
Pseudobronchictasis Pertussis
Complications of bronchiectasis Amyloidosis, lung abscess, cerebral abscess
NOT a complication of bronchiectasis Lung cancer
NOT seen in Bronchiectasis Pleural effusion
Best method for detecting minimal bronchiectasis CT scan
Investigation of choice for Bronchiectasis High Resolution CT Scan
Best method for diagnosing minimal bronchiectasis CT scan
NOT an indication of surgery in bronchiectasis Negative bronchiectasis
INTERSTITIAL LUNG DISEASE
Most common type of interstitial lung Lymphocytic interstitial pneumonia

disease in children
Drugs associated with ILD Amiodarone, carmustine
Pulmonary fibrosis caused by Busulfan, Methotrexate, bleomycin
Does NOT cause interstitial lung disease Alpha methyl dopa
Characteristically NOT associated with interstitial lung Tobacco smokes
disease
Female, progressive breathlessness, heterogenous Usual interstitial pneumonia
patchy fibrosis with several fibroblastic foci
Idiopathic pulmonary fibrosis is also Cryptogenic fibrosing alveolitis
known as
Crackling crepitations unaltered by coughing Interstitial lung disease
Interstitial lung disease is associated with Dry crackles
Earliest manifestation of Interstitial fibrosis Alveolitis
Honey comb lung is seen in Idiopathic Pulmonary fibrosis
Reverse halo sign Cryptogenic organizing pneumonia
ILD associated with tuberous sclerosis Affects women only, spontaneous
pneumothorax, obstructive pattern (other
types of ILD shows restrictive pattern)
ILD associated with sarcoidosis Substernal discomfort
NOT associated with interstitial lung disease Inhalation of tobacco smoke
Alveolar hemorrhage is NOT seen in Idiopathic Pulmonary fibrosis
Generally presents in elderly, often associated with HHV PFT for interstitial lung disease
8, patients are commonly HIV positive, proliferating cell
what
Interstitial lung disease FVC < 80% of predicted, DLCO is decreased, TLC is
decreased, Increased FEV1/FVC > 0.7, May be
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RESPIRATORY SYSTEM
associated with connective tissue disorders

Most sensitive test for interstitial lung disease DLCO
KCO (DLCO, transfer factor) is decreased Fibrotic lung disease
in
X ray feature of idiopathic pulmonary Patchy fibrosis
fibrosis
HRCT used in Interstitial lung disease
Investigation of choice for Interstitial Lung Disease HRCT Scan
Biopsy finding of idiopathic pulmonary Fibroblast proliferation with fibroelastosis
fibrosis
PNEUMOCONIOSIS
Most dangerous particle size for Pneumoconiosis 1 – 5 micron

Optimal particle size for pneumoconiosis 0.5 to 3 microns
Caplan syndrome is seen in Pneumoconiosis
Hard metal Tungsten carbide
OCCUPATIONAL LUNG DISEASE
Hot tub lung Hypersensitivity to mycobacterium avium complex,

cladosporium
Farmer’s lung/Bagassosis Thermophilic acinomycetes
Thermophilic actinomyces cause Bagassosis, mushroom worker lung
disease, farmer lung disease
Cheese washer’s lung Penicillium casei
Chemical worker lung Isocyanates
Compost lung Aspergillus
Detergent worker lung Bacillus subtilis
Japanese summer type lung Trichophyton cutaneum
Laboratory worker HP Male rat urine
Malt worker lung Aspergillus fumigates
Maple bark disease Cryptosoma corticale
Metal working fluid lung Mycobacterium, pseudomonas
Miller’s lung Sitophilus granaries – infested wheat flour
Sauna taker lung Aureobasidium
Sequoiosis Aureobasidium
Sausage worker lung Penicillium nalgiovense
Suberosis Penicillium glabrum, chrysonilia sitophilia (cork dust)
Tap water lung Mycobacteria
Thatched roof disease Saccharomonopor viridian
Tobacco worker lung Aspergillus
Wine grower lung Botrytis cinera
Wood trimmer lung Rhizopus, mucor
Brewer lung Aspergillosis
Silo filler disease Inhalation of nitrogen dioxide from fresh
silage
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RESPIRATORY SYSTEM
ASBESTOSIS
MC form of asbestosis Serpentine

Most pathogenic form of asbestosis Amphibole
MC Lesion in Asbestosis Benign Pleural Plaques
Earliest lesion seen in asbestosis is Pleural plaques
A 35 year old with history of asbestos exposure Round atelectasis
presents with chest pain. X ray shows solitary
pulmonary nodule adjoining of right lower costal pleura
with comet tail sign and adjacent pleural thickening
Asbestosis is responsible for Bronchogenic carcinoma, gastric carcinoma,
mesothelioma(pleural and peritoneal), pulmonary
fibrosis
Extensive pleural thickening and calcification especially Asbestosis
involving diaphragmatic pleura
Findings in Asbestosis Calcify pleural plaques, diffuse pulmonary interstitial
fibrosis, mesothelioma, Fine reticular and nodular
pattern in lower zone with loss of clarity of diaphragm
and cardiac shadows.
Asbestos factory mass in apical lobe. HPE Desmosomes
Ferruginous Bodies Asbestosis
Lower lung involvement is common in Asbestosis
Asbestosis NOT associated with Methemoglobulinemia
Condition NOT associated with asbestosis Bronchiectasis
NOT seen in asbestosis Emphysema
Asbestosis NOT associated with Nodular lesion in upper lobe
NOT true about asbestosis Occur within 5 years of exposure
NOT seen in Asbestosis Diffuse alveolar damage
Asbestosis does NOT cause Arthralgia
Solitary fibrous tumor of pleura (benign CD34+
mesothelioma)
Asbestosis is usually related to Mesothelioma
Mesothelioma of Pleura is due to Crocidolite
Mesothelioma Hypoglycemia, associated with asbestosis, hemorrhagic
pleural effusion, clubbing of fingers
Mesothelioma Not bilateral, not symmetrical
Pleural mesothelioma is associated with Asbestosis
Biopsy finding of mesothelioma of pleura Microvilli invasion, intense fibrosis
Marker for mesothelioma Calretinin
NOT true about mesothelioma Bilaterally symmetrical
SILICOSIS
MC Chronic Occupational disease in world Silicosis

Silicosis is associated with Free silica
Silicosis occurs with Silica fibres
Pneumoconiosis first reported in KGF Silicosis
Silicosis affect Upper lobe of lung
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RESPIRATORY SYSTEM
Tuberculosis commonly occurs in Silicosis

Extensive nodular pulmonary fibrosis is associated with Silica
Base is SPARED in Silicosis
NOT true about silicosis Pleural plaques
NOT a feature of silicotuberculosis High AFB+ sputum
Snowstorm appearance in X ray chest Silicosis
HRCT in silicosis Crazy paving
Only way of Silicosis control Rigorous dust control
PULMONARY HEMOSIDEROSIS
Triad of idiopathic pulmonary hemosiderosis Iron deficiency anemia, Diffuse alveolar hemorrhage,
Hemoptysis
Idiopathic pulmonary hemosiderosis associated with Alveolar capillary dilatation
HYPERSENSITIVE PNEUMONITIS
Hypersensitive pneumonitis Type III immune complex

Associated with hypersensitive pneumonitis Byssinosis
Prediction rule applies to Hypersensitive pneumonitis
Known trigger of hypersensitive Aspergillus spores
pneumonitis
EOSINOPHILIA
Tropical pulmonary eosinophilia Eosinophilia > 3000/mm3, Paroxysmal cough and

wheeze, Bilateral chest mottling and increased
bronchovascular markings
Pulmonary eosinophilic pneumonia associated with ABPA, Loeffler’s pneumonia, churg strauss syndrome,
tropical pulmonary eosinophilia
Pulmonary eosinophilia is NOT due to Babesiosis
NOT a feature of Tropical Eosinophilia Microfilaria in blood
NOT associated with peripheral blood eosinophilia Pulmonary eosinophilic granuloma
ASPERGILLOSIS
ABPA is associated with Perihilar bronchiectasis

40 year old man presented with repeated episodes of Bronchopulmonary aspergillosis
bronchospasm and hemoptysis, chest X ray revealed
perihilar bronchiectasis
Bronchial asthma may be complicated by infection with Aspergillus fumigates
Diffuse pulmonary infiltrates on X ray with normal levels Extrinsic allergic alveolitis
of IgE and absence of peripheral eosinophilia
Features of extrinsic allergic alveolitis Headache, myalgia, bilateral
reticulonodular shadows
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RESPIRATORY SYSTEM
NOT a feature of extrinsic allergic Bronchial asthma and wheeze

alveolitis
Diagnostic features of allergic bronchopulmonary Changing pulmonary infiltrates, peripheral eosionphilia
aspergillosis > 1000/mm3, serum precipitins against aspergillus
fumigans, central bronchiectasis, episodic asthma, IgG
antibodies specific to aspergillus fumigatus, detection
of aspergillus in sputum
NOT true about Allergic Bronchopulmonary Distal bronchiectasis
Aspergillosis
NOT true about bronchopulmonary aspergillosis Pleural effusion
NOT true about ABPA Invasive
Military mottling of lung NOT seen in Aspergillosis
Aspergillosis is NOT associated with Malignant lung
NOT a diagnostic feature of ABPA Occurence in patients with old cavitatory lesions
NOT true about ABPA Lower lobe predominance
NOT true about aspergillosis Highly contagious
Best diagnosis for pulmonary mycosis Sputum examination
BRONCHIOLITIS
MC etiology for acute bronchilitis in infancy Respiratory syncitial virus

Bronchiolitis in children is caused by RSV, Mycoplasma, Influenza virus
Acute bronchiolitis is NOT caused by Measles
Bronchiolitis Common in boys, RSV immunoglobulin does NOT have
any role in acute episode
Chest X ray in bronchiolitis Bilateral hyperinflation
HIV positive child, URTI, hyperinflation O2 saturation Ribavirin
greater than 90%
Drug of choice in Bronchiolitis Ribavirin
A month old child HIV positive, following URTI develops Ribavirin
sudden onset of breathlessness. Chest X ray shows
hyperinflation.O2 saturation >90%. Treatment
NOT a drug of choice for Bronchiolitis IV Bronchodilators
LARYNGOTRACHEOBRONCHITIS
Croup syndrome (acute laryngotracheobronchitis) is Parainfluenza

caused by
3 days history of upper respiratory tract infection Laryngotracheobronchitis
presents with stridor which decreased on lying down
posture
Hoarseness followed by stridor is seen in Acute Laryngotracheobronchitis
Barky cough is seen in Acute laryngotracheobronchitis
Laryngotracheobronchitis More common in boys, narrowing of subglottic space
with ballooning of hypopharynx
Steeple Sign Narrowing of Subglottic Region
NOT true about laryngotracheobronchitis Antibiotics are main stay of treatment
Combination chemotherapy NOT indicative in Laryngotracheobronchitis
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RESPIRATORY SYSTEM
2 years old child, fever barking cough and stridor only High dose dexamethasone
when crying. Able to drink normally RR 36/min.
temperature 39.6*C. Next step
May be helpful in croup Heliox
BRONCHIAL FOREIGN BODY
Commonest site of impaction of fish bone Palatine tonsil

Most commonly aspirated foreign body Nuts
Most common site of foreign body Right bronchus
MC cause of sudden severe dyspnea in 2 year old child Foreign body
A child with acute respiratory distress showing Foreign body aspiration
hyperinflation of unilateral lung in X ray is due to
2 year boy, sudden onset of stridor and respiratory Foreign body aspiration
difficulty. The chest examination reveals decreased
breath sounds and wheeze in right side. X ray showed
opaque right hemithorax
Commonest sign of intrabronchial foreign body in Cough
children
Hoarseness of voice, Croupy cough, Asthmatic wheeze Foreign body larynx
Foreign body in Lung involves Apical segment of Right Lower Lobe
Foreign body lung involves Right middle and inferior apical
In erect posture, common site of foreign body in Right posterior basal
bronchus
Foreign body aspiration in supine position Apical part of right lower lobe
Foreign body in supine position lodge Right upper lobe
Coin in the larynx is stuck Coronally
Coin in trachea Horizontally
Foreign body completely obstructing right main Decreased ventilation perfusion ratio
bronchus
Inhaled foreign body is likely to lodge in right lung Right principal BRONCHUS is shorter, wider and more
vertical than left, Tracheal bifurcation directs foreign
body to right lung, Right inferior lobar bronchus is in
continuation with the principal bronchus
NOT a feature of Foreign body aspiration Dull chest wall on Percussion
NOT true about is foreign body larynx In foreign body larynx, blind single finger sweep is
always done
Investigation for Inhaled Foreign body in Infant Bronchoscopy
Immediate management of child with foreign body Bronchoscopy
Anesthesia given in bronchoscopy Jet ventilation
Sudden distress aphonia and respiratory distress while Heimlich’s maneuver
having dinner, next step
Position for removal of foreign body Boyce position (supine with extension of
head and flexion of neck)
Correct sequence of resuscitating an infant Back blow, tongue jaw lift, chest thrust
with foreign body airway obstruction
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PLEURAL EFFUSION, PNEUMOTHORAX AND MEDIASTINITIS 37
RESPIRATORY SYSTEM
BRONCHOSCOPY
Openings of tube of bronchoscope Vent

Placement of double lumen tube best confirmed by Fiber optic bronchoscopy
Direct bronchoscopy cannot visualize Subcarinal lymphnodes
NOT a contraindication for bronchoscopy Trismus
NOT a contraindication for bronchoscopy Active bleeding
MC danger of fiber optic bronchoscopy Hypoxemia
SOLITARY NODULE
NOT a cause of solitary pulmonary nodule Neurofibroma

Best investigation for solitary pulmonary nodule on X Image guided biopsy
ray
PLEURAL EFFUSION, PNEUMOTHORAX AND MEDIASTINITIS
GENERAL FEATURES OF PLEURA
Parietal pleura Pain sensitive

th
Right costophrenic recess extends up to the level of 10 rib in mid axillary line
Spring water cyst Pleuropericardial cyst
Primary pleural tumor Mesothelioma
PLEURAL EFFUSION
MC cause of Pseudochylous Pleural effusion Ca Lung

NOT a common cause of pleural effusion Hypothyroidism
First part of Pleural cavity filled in Pleural effusion Costodiaphragmatic
Pleural effusion Horizontal fluid level, Succussion splash
Left sided pleural effusion Pancreatitis, Esophageal rupture
Loculated pleural effusion It makes an obtuse angle with chest wall, Margins are
diffuse when viewed end on, Not confined to any
bronchopulmonary segment
Exudative pleural effusion Bronchogenic carcinoma, Rheumatoid arthritis
Specific gravity of transudate < 1.012
Transudate pleural effusion Peritoneal dialysis
Transudate pleural effusion Nephrotic syndrome, Constrictive pericarditis,
Myxedema, Pulmonary embolism
Transudate pleural effusion Hemorrhagic effusion, Increased deaminase, Pleural
fluid LDH more than 60% of serum LDH
NOT a transudate Uraemic Pleuritis
Decreased glucose in pleural effusion Rheumatoid arthritis, Pneumococcal infection,
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RESPIRATORY SYSTEM
Malignant pleural effusion, Empyema, Mesothelioma

Cholesterol crystal in pleural effusion Myxoedema
Amylase increased in pleural fluid Malignancy, Esophageal rupture, Pancreatitis
Bilateral pleural effusion NOT seen in Meig’s syndrome
Modality used in differentiating benign and malignant PET
pleural disease
Interlobar pleural effusion can be detected by Reverse lordotic view
Ipsilateral Lateral Decubitus Minimal Pleural Effusion
Best method to detect minimal pleural effusion Right lateral decubitus
Best investigation for right pleural effusion Right lateral decubitus
NOT an indication of thoracotomy Pulmonary contusion
Chest tube insertion in parapneumonic effusion is NOT Loculated Pus
done for
Needle used for pleural biopsy Abram’s needle
th
MC site of putting chest drain in pleural effusion 7 intercostal space in midaxillary line
While doing thoracocentesis, it is advised to introduce Upper border of rib
needle along
A pt presented with a penetrating injury in chest Internal thoracic artery
associated with intrathoracic hemorrhage. A
th th
thoracotomy is done by taking an incision in 4 /5
intercostals space starting 1 cm away from lateral
margin of sternum. This is done to avoid injury to
Cut in posterolateral thoracotomy Serratus anterior, Latissimus dorsi, Intercostals
NOT cut in posterolateral thoracotomy Pectoralis major
Muscle NOT cut in posterolateral thoracotomy Rhomboids major, Pectoralis major
Muscle NOT pierced in pleural tapping in mid axillary Tranversus thoracis
line
Pleural tap does NOT pierce Pulmonary pleura
HEMOTHORAX
th
Complication expected when PCNL is done through 11 Hydrothorax
intercostal space
Hemothorax Seen in choriocarcinoma, Supine position better than
erect posture, Needle aspiration may be needed for
diagnosis
Excessive bleeding during hemothorax is caused usually Major artery
by
Opacity on chest X ray soon after blunt chest injury Hemothorax
Liver dullness NOT obliterated in Hydrothorax
Ideal treatment of hemothorax of blood loss greater Open thoracotomy with ligation of vessel
than 500 ml/hour
Treatment of acutely developing massive left sided Tube thoracostomy
hemothorax in a young male after an accident
Surgery in case of hemothorax due to blunt injury based Hemodynamic status > nature of chest tube output
on
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RESPIRATORY SYSTEM
PNEUMOTHORAX
Pneumothorax in a newborn is due to Hyaline membrane disease, meconium aspiration

syndrome
MC cause of Non progressive pneumothorax Rupture of subpleural bleb
Pneumothorax is seen in Marfan syndrome, Assisted ventilation, Eosinophilic
granuloma
While inserting Central venous catheter, patient Pneumothorax
develop respiratory distress
Hypoxemia and respiratory distress after CVP insertion Pneumothorax
Absent breath sounds, hyper resonant chest wall during Iatrogenic pneumothorax
subclavian vein cannulation
Pneumothorax Decreased breath sound, Increased percussion note,
Often need chest tube insertion
Left sided pneumothorax associated with RIGHT axis deviation, Absent R wave
Peak P wave, Precordial T wave insertion
Left pneumothorax Inversion of T wave, small R wave, electrical alterans
ECG in massive Left Pneumothorax causes Left axis deviation
Stratosphere sign Pneumothorax
Best view to diagnose pneumothorax PA view in full expiration
PA View in Full Expiration Pneumothorax
Pneumothorax is best diagnosed by taking radiograph Full expiration
with patient in
X ray features pneumothorax Hyperluscency, collapse of ipsilateral lung,
absent lung markings
Treatment of choice for pneumothorax due to blunt Intercostal drainage
injury
Patient with one episode of pneumothorax Stop diving, flying, smoking
Heimlich valve used in drainage of Pneumothorax
NOT an indication of endotracheal intubation Pneumothorax
Characteristic of primary spontaneous pneumothorax Male gender, YOUNG age, Tall stature, History of
smoking
Management of Spontaneous Pneumothorax Needle Aspiration
Chest tube should be inserted in spontaneous 25%
pneumothorax exceeding
nd
MC Site of Putting Needle in Spontaneous 2 Intercostal Space Mid Clavicular Line
Pneumothorax
Intrapleural pressure is equal to atmospheric pressure Open Pneumothorax
in
Management of open pneumothorax ICD with underwater seal
Lung injury with bad prognosis Tension pneumothorax
Following a major trauma a patient presented 54 hours Tension pneumothorax, Cardiac tamponade
later with raised JVP and CVP of 16 mm Hg and
persistent hypotension
Acute respiratory distress in staphylococcal pneumonia Tension pneumothorax
is due to
Pneumothorax of more than 25% require Tube thoracostomy
Tension pneumothorax due to fracture rib is treated by Tube drainage
Tension pneumothorax results in Decreased venous return
Treatment of Tension pneumothorax Large bore needle puncture of pleura
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RESPIRATORY SYSTEM
Best treatment of tension pneumothorax Immediate letting out of air

Management of victim of road traffic accident with Insert needle in second ICS
tension pneumothorax
LUNG SEQUESTRATION
A 4 years child presents with a history of chornic left Pulmonary sequestration

lower lobe pneumonitis. On contrast bronchography,
the area involved with the pneumonitis does not fill
whereas the area around it does fill. Diagnosis
Sequestration of Lung Posterior part of Left Lung
Lung sequestration most commonly occurs in Left posterior basal
Intralobar sequestration of lung takes its blood supply Descending abdominal aorta
from
Intralobar sequestration is connected to Airway
Intralobar sequestration is seen in Neonates
Diagnosis of lung sequestration CT
Investigation of choice for lung sequestration Angiography
MEDIASTINUM
Mediastinum Left brachicephalic vein passes anterior to

brachicephalic artery, Left recurrent laryngeal nerve
passes under arch of aorta
Right border of mediastinum is formed by IVC, Innominate vein, Innominate artery
Right border of mediastinum in X ray is formed by SVC, Right atrium, Right brachiocephalic vein
Right side of mediatinum shadow is NOT formed by Right ventricle
Mediastinum of Pericardium Anterior mediastinum
Arch of aorta is situated in Superior mediastinum
Esophagus NOT seen in Which Mediastinum Middle Mediastinum
Commonest lesion in middle mediastinum Aneurysm
MC cause of acute mediastinitis Esophageal perforation
MC cause of chronic mediastinitis Tuberculosis
Chronic mediatinitis Histoplasmosis, Sarcoidosis, Tuberculosis
Hamman Rich syndrome is treated with Steroids
Organism commonly related to mediastinal fibrosis Histoplasma
Majority of lung cyst occur in Mediastinum
MC primary tumor of mediastinum Neurogenic tumor
Anterior mediastinal tumors Thymoma, Aortic aneurysm, Lymphoma
NOT a differential diagnosis of anterior mediastinal Neurogenic tumor
tumor
Posterior mediastinal tumor Neuroblastoma, Bronchogenic cyst, Neuroenteric cyst,
Lymphoma
MC tumor of posterior mediastinum Neurofibroma
Thymic swelling Widening of mediastinum on X ray, Sharp border with
snail like appearance, Steroid administration reduces
size of swelling
NOT a feature of thymic swelling Shift of trachea on X ray
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PNEUMONIA 41
RESPIRATORY SYSTEM
First affected in mediastinal syndrome Veins
BRONCHOPLEURAL FISTULA
Greatest incidence of bronchopleural fistula following Lobectomies

Investigation of choice for traumatic bronchopleural X ray
fistula
Failure to establish adequate drainage in empyema with Continued productive cough with purulent material
bronchopleural fistula is indicated by
PNEUMONIA
GENERAL FEATURES OF PNEUMONIA
Fever persisting even after treatment of pneumonia Empyema, fungal lesion, carcinoma bronchus
Bacterial pneumonia associated with cavitation Staphylococcus, Klebsiella, Pneumonia, Anaerobic
bacteria
Pneumonia in paper mill worker Bagassosis
Nezelof syndrome Recurrent episodes of pneumonia
Air bronchogram Pneumonia
Air bronchogram is associated with Consolidation, pulmonary edema, alveolar
cell carcinoma
Spine sign Right lower lobe pneumonia
Group A streptococcus is associated with Interstitial pneumonia
NOT true about aspiration pneumonia Fungal infection common cause
In Pneumonia Severity Scale, most important factor is Age
CURB65 Confusion, urea, respiratory rate, blood pressure, age > 65
CPIS Clinical pulmonary infection score, maximum 12
NOT a complication of lobar pneumonia Amyloidosis
NOT true about laboratory diagnosis of viral respiratory Detection of viral hemagglutination inhibiting
tract infections antibodies in a single serum specimen
MC cause of nosocomial pneumonia in Staphylococcus > gram negative bacilli
neonates
RR above which a less than 2 month baby is abnormal 60
Important sign in respiratory disease Retraction
Most indicative sign of Pneumonia in 1 year old child Grunting and RR>60
with cough and fever
2 year boy, cough fever and difficulty in breathing. RR Pneumonia
50, no chest indrawing, bilateral crepitus
Drug of choice for pneumonia in CSSM Cotrimoxazole
Recommended dose for treatment of pneumonia of 6 One tablet twice daily
months old child
2 years, fever for past 2 days, weight 11 kg. RR 38/min, Classify as severe pneumonia, start antibiotics and refer
chest indrawing urgently
Chest indrawing is associated with Severe pneumonia
Severe pneumonia Refer urgently to hospital after giving first dose of
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PNEUMONIA 42
RESPIRATORY SYSTEM
antibiotic
A 2 year old cough and fever for 4 days with inability to Very severe disease
drink for last 12 hours. Weight 5kg and RR 45/min with
fever.
WHO criteria for admission in pneumonia High fever, Nasal flaring, Difficulty in feeding, Chest
indrawing
In ARI control programme, category NOT Pneumonia
present in child less than 2 months
Clinical pulmonary infection score Fever, leucocytosis, oxygenation, chest X
ray, tracheal aspirate
CAUSES OF PNEUMONIA
MC organism responsible for Nosocomial Pneumonia in Gram Negative Organism

ICU
MC cause of Pneumonia in Renal transplant patient CMV
MC cause of Bronchopneumonia Staphylococcus aureus
MC cause of Lobar Pneumonia Streptococcus pneumonia
MC cause of Community Acquired Pneumonia Streptococcus pneumonia
MC cause of Viral Pneumonia in Infants RSV
MC cause of bulging of Lung Fissure Klebsiella pneumonia
NOT a causative agent of bronchopneumonia Mumps virus
MORPHOLOGY OF PNEUMONIA
Stage of lobar pneumonia which has Grey hepatization

predominantly fibrosuppurative exudates
Grey hepatisation seen on 5-7 day
NOT a stage in Pneumonia Stage of Organisation
Resolution of Pneumonia is diagnosed Pathologically
VIRAL PNEUMONIA
Viral pneumonia Interstitial inflammation, bronchiolitis, multinucleate

giant cells in bronchial wall
NOT seen in viral pneumonia Predominant alveolar exudates
STAPHYLOCOCCAL PNEUMONIA
Staphylococcal Pneumonia Pneumatocele

Cavitatory lesions in lung seen in Staphylococcal pneumonia
Chest ray with multiple thin walled cavities in acutely Staphylococcal pneumatoceles
toxic child
Acute Respiratory distress in Staphylococcal pneumonia Tension Pneumothorax
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PNEUMONIA 43
RESPIRATORY SYSTEM
due to
STREPTOCOCCAL PNEUMONIA
Streptococcus pneumonia is Alpha hemolytic

Predisposing factors for pneumococcal pneumonia CRF, lymphoma, old age, sickle cell disease
MC focal complication of pneumococcal pneumonia Empyema
Features of streptococcal pneumonia Lobar pneumonia, non patchy
involvement of single lobe
Subdural empyema is commonly caused by Streptococcus pneumonia
Drug NOT used for Streptococcal Pneumonia Gentamicin
ATYPICAL PNEUMONIA
MC cause of atypical Pneumonia Mycoplasma pneumonia

Atypical pneumonia is caused by Legionella
Atypical pneumonia Mycoplasma pneumonia, Legionella pneumophila,
Human corona virus, Chlamydia
NOT a cause of Atypical pneumonia Klebsiella pneumonia
Mycoplasma pneumoniae Diffuse infiltration of drug, Cannot be cultured
routinely, Serology is useful in diagnosis
Mycoplasma pneumonia is associated with Submucosal inflammatory response
Resistant to antibiotic acting on cell wall Mycoplama pneumonia
Elevated levels of Cold agglutinins are seen in Primary atypical Pneumonia
Primary atypical pneumonia caused by Mycoplasma is Streptococcal MG test
diagnosed by
Drug of choice for mycoplasma pneumonia Azithromycin
Staccato cough is associated with Chlamydia infection
Treatment of chlamydia pneumonia Erythromycin
MC site of aspiration pneumonia Right apical lobe
Commonest sign of aspiration pneumonitis Tachypnea
COMMUNITY ACQUIRED PNEUMONIA
MC cause of community acquired E.coli

pneumonia in newborn
MC cause of community acquired Pneumococcus > Chlamydia >
pneumonia Mycoplasma
Causes of community acquired pneumonia H.influenza, Streptococcus pneumonia, Mycoplama
pneumonia
NOT a cause of community acquired pneumonia Acinetobacter
Outpatient treatment of community acquired Azithromycin, Doxycycline
pneumonia
Duration of antibiotic therapy for community acquired 3-5 days
pneumonia
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PNEUMONIA 44
RESPIRATORY SYSTEM
CMV PNEUMONIA
Type of pneumonia caused by CMV Diffuse Interstitial Pneumonia

Bilateral diffuse interstitial Pneumonia after renal CMV
transplant
Patient with AIDS pneumonia inclusion bodies CMV pneumonia
LEGIONNAIRE’S PNEUMONIA
Pneumonia with hyponatremia is seen in Legionella

Legionnaire’s pneumonia presents with Diarrhea, Bilateral infiltrates, dry cough
Female, diarrhea, confusion, high grade fever, bilateral Legionella
pneumoconitis
Treatment of pneumonia and diarrhea days after Azithromycin, Levofloxacin (Legionella infection)
discharge from hospital
KLEBSIELLA PNEUMONIA
Friedlander bacilli Klebsiella pneumoniae

String test for Hypervirulent variant of Klebsiella
Klebsiella pneumonia Chocolate coloured sputum, involvement of upper
lobes of lung, systemic disturbance, high mortality
Red currant jelly sputum Klebsiella pneumonia
Characteristic radiological feature of Klebsiella Prominent horizontal fissure
pneumonia
NOT used to treat Klebsiella infection Ampicillin
PNEUMOCYSTIS CARNII PNEUMONIA
Pneumocystis carnii pneumonia Interstitial pneumonitis, eosinophilic alveolar exudates,

damage to type I pneumocytes, hypertrophy of type II
pneumocytes, foamy vacuolated exudates, neutrophil
infiltration, mononuclear cell in bronchoalveolar
damage
Pneumocystis carnii pneumonia MAY be associated with CMV infection, Associated with
pneumatocele, Usually diagnosed by sputum
examination, Disease only in immunocompromised host
Characteristic histopathologic feature of pneumocystis Eosinophilic alveolar exudates
carnii pneumonia
A patient suffering from AIDS presents with history of Pneumocystis carnii pneumonia
dyspnea and non productive cough. X ray shows
bilateral perihilar opacities without pleural effusion and
lymphadenopathy
Perihilar ground glass haziness ARDS, pulmonary edema, pneumocystis
carnii pneumonia
Bilateral interstitial infiltrates in chest X ray in HIV Pneumocystis carnii pneumonia
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PNEUMONIA 45
RESPIRATORY SYSTEM
patient
AIDS patient with hat shaped structures in alveoli about Pneumocystis carnii pneumonia
the size of erythrocyte and stain with silver
Black bronchus sign Pneumocystis carnii pneumonia
Infection associated with humoral immunodeficiency Pneumocystis carnii pneumonia
Pneumocystitis carnii pneumonia is associated with Inflammation of type II alveolar cells
Humoral immunodeficiency NOT seen in Pneumocystis carnii pneumonia
NOT true about Pneumocystis carnii pneumonia Lobar Pneumonia
Chest X ray finding in Pneumocystis carnii pneumonia Bilateral diffuse infiltrates beginning in perihilar region
Treatment of pneumocystis carnii pneumonia Pentamidine, Dapsone, Cotrimoxazole
Treatment of pneumocystis carnii pneumonia intolerant to Pentamidine
cotrimoxazole
Side effect of pentamidine Pancreatitis
EMPYEMA
MC cause of empyema Bacterial pneumonia

Most common cause of Empyema Unsolved pyogenic pneumonia
MC cause of empyema under 2 years Staphylococcus
Parasitic causes of empyema Paragonimus westermani, echinococcus
granulosus, entamoeba coli
Empyema necessitans Pleural empyema showing extension to subcutaneous
tissue
NOT a complication of empyema Pneumonia
Best treatment for localized thick empyema Rib resection, drainage, antibiotics
LUNG ABSCESS
Commonest cause of lung abscess Aspiration

Primary lung abscess is commonly due to Bronchial embolism aspirating from infected sinus
NOT a cause of lung abscess in children Pneumococcus
MC site of lung abscess Left upper lobe
80 year old male presented with lung abscess in left Antibiotic according to organism
upper zone. best treatment modality
Treatment of lung abscess Clindamycin (anaerobic), Vancomycin (S.aureus)
Lung abscess is NOT seen in Lobar Pneumonia
MC cause of amoebic lung abscess Direct extension from liver
Hydatid cyst of lung Common in lower lobe
Treatment of hydatid cyst of lung Excision of cyst
BROCHIOLITIS OBLITERANS
Smoking is NOT a risk factor for Bronchiolitis Obliterans Organising pneumonia

7 ½ month old child, cough and mild stridor started on Bronchiolitis obliterans
oral antibiotics, showed initial improvement but later
developed wheeze, productive cough, mild fever. X ray
shows hyperluscency and PFT shows an obstructive
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TUBERCULOSIS 46
RESPIRATORY SYSTEM
curve
Features seen in bronchiolitis obliterans with organizing Polypoid plugs in bronchioles, Exudation of
pneumonia proteinaceous material in terminal airways,
Bronchoconstriction, Response to steroids
MANAGEMENT OF PNEUMONIA
Treatment of Post measles Bronchopneumonia Antibiotics and Oxygen

Drug of choice of Mycoplasma pneumonia in children Erythromycin
Drug for Pneumonia Cotrimoxazole
Drug for Severe Pneumonia Benzyl Penicillin
Drug for Very Severe Pneumonia Chloramphenicol
TUBERCULOSIS
MYCOBACTERIUM TUBERCULOSIS
Mycobacterium tuberculosis was discovered by Robert Koch

Mycobacterium tuberculosis Niacin positive
Not easily cultivable but well viable and used for Mycobacterium tuberculosis
epidemiology
Colonies of mycobacteria Rough, tough, buff, non pigmented
Factor promoting virulence of M.tuberculosis Cord factor
Cord factor (mycoside) 2 mycodic acid with trubalose
Wax D is Complicated mycoside
Acid fast positive with 20% sulphuric acid Mycobacterium tuberculosis
Generation of tuberculous bacteria 20 hours
Phagocytosis of tuberculous bacillus does not occur Cord factor
because of
Can be transmitted by droplet infection Tuberculosis
Buruli ulcer is caused by Mycobacterium ulcerans
Johne’s bacillus Mycobacterium paratuberculosis
Mycobacterium bovis Resistant to pyrazinamide, cause of TB transmitted by
unpasterurized milk
Vole bacillus Mycobacterium microti
Tests to differentiate tubercular bacteria Aryl sulphatase test, niacin test
from atypical mycobacteria
EPIDEMIOLOGY OF TUBERCULOSIS
McKneown theory states that reduced prevalence of Social and economic factors
tuberculosis occurs due to
Rural and urban difference in prevalence is NOT seen in Tuberculosis
Disease NOT showing difference in incidence in rural TB
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TUBERCULOSIS 47
RESPIRATORY SYSTEM
and urban population

Barometer of social welfare Tuberculosis
Albert Calmette and Camille Guerin Tuberculosis
Trend of Tuberculosis in community is assessed by Tuberculin Conversion Index
Incidence of tuberculosis in a community Sputum smear positivity
Peripheral health institution under District tuberculosis Microscopy + Radiological facilities
centre is designated as PHIR when it has
Method of choice for TB detection in mass screening Tuberculin test
Prevalence of TB in a community Tuberculin test
If the objective of the investigator is to assess incidence Identify new converters to tuberculin test
of TB in community, most appropriate methodology
Mantoux test Positive test does not indicate the person is suffering
from the disease
Percentage of positive mantoux test in Indian in 20-40 20-30%
years age group
A patient with sputum positive pulmonary tuberculosis Failure case
on treatment with ATT treatment for 5 months. still
positive for AFB
National tuberculosis institute Bangalore
Voluntary organization Tuberculosis association of India
Best in prevention of tuberculosis and leprosy Health education
WHO defines Tuberculosis Control strategy by Prevalence of infection in age group < 4 years
Voluntary organization Tuberculosis association of India
Best method for assessing preventive measure in Presence of infection
control of TB
Decrease in which of the parameter indicate decrease Incidence of disease
in tuberculosis problem in India
Incidence of open tuberculosis 4%
Incidence of tuberculosis in India 1.5/1000
Prevalence of bacteriologically controlled 4/1000
TB in India
Prevalence of Tuberculosis infection in 30%
India
Tuberculosis is considered to be under control if < 4% under 14 years
incidence is
Overall prevalence of tuberculosis infection in India as 40%
th
per 4 round of longitudinal survey
Tuberculosis annual rate of infection ARI India 1.7%, reflects current trend and effectiveness
of control measures, percentage of new infections
Annual risk of TB It is assessed by tuberculin conversion in previously non
vaccinated children
FEATURES OF TUBERCULOSIS
MC cause of pyrexia of unknown origin Mycobacterium tuberculosis

Under passive surveillance for tuberculosis, indication 2 weeks
of sputum microscopy cough more than
MC cause of Massive Hemoptysis in India Tuberculosis
MC cause of Cavitation Tuberculosis
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TUBERCULOSIS 48
RESPIRATORY SYSTEM
MC allergic manifestation of tuberculosis Koeppe’s nodule

MC cause of Pyrexia of Unknown Origin Mycobacterium tuberculosis
MC cause of tree in bud appearance Mycobacterium tuberculosis
nd rd
MC cause of tree in bud appearance after CMV, 2 RSV, 3 Mycobacterium tuberculosis
hematopoietic Stem cell transplantation
Tree in bud is associated with Atypical mycobacterial infection
Barometer for social welfare Tuberculosis
Koch’s Phenomenon Tuberculosis
Primary cells infected by Mycobacterium tuberculosis Macrophages
Earliest feature of tuberculosis Recruitment of lymphocytes, Lymphocytosis
Reactivated TB commonly occur near Apex
Presentation of primary TB Unilateral hilar lymphadenopathy
Primary tuberculosis mostly involves Lungs
MC site of primary infection in congenital tuberculosis Liver
Every sputum positive TB patient can 10 – 15 patients
infect up to
8 year boy, fever and bilateral cervical Tuberculosis
lymphadenopathy, prior history of sore throat. No
hepatomegaly. Peripheral blood smear shows >20%
lymphoplasmocytoid cells
Upper lobe fibrotic lesion and mediastinum had Tuberculosis
enlarged necrotic nodes with peripheral rim
enhancement
Posterior cervical lymphadenopathy in children is TB
commonly due to
Tuberculosis For sputum positive bacilli should be >10000/ml, niacin
test differentiates M.tuberculosis and M.bovis,
pathogenecity to rabies differentiate M.tuberculosis
and M.bovis
In HIV patient, tuberculosis Decreased cavitation, decreased fibrosis, highly variable
tuberculin test
Reservoir of Infection in TB Human being with active TB
MC Form of Extrapulmonary TB Lymphadenopathy
Tuberculous lymphadenitis Seen in children and young adults, History of contact or
drinking infected milk
Tuberculous lymph node Soft, fluctuant, matted, sinus formation,
conglomeration of nodes
Tuberculous pleural effusion Hemorrhagic effusion, Pleural LDH more than 60% of
serum LDH, protein in aspirational fluid is increased
Pleural effusion without evident lung infiltration is most Tuberculosis
often due to
Feature of tubercular ulcer Thin serpiginous ulcer with undermined edges
Can cause disease indistinguishable from tuberculosis Mycobacterium kansasii
Breast milk is known to transmit Tuberculosis
NOT transmitted during incubation period Tuberculosis
Primary tuberculosis does NOT occur in Meninges
NOT a complication of Pulmonary tuberculosis CO2 retention
Pulmonary tuberculosis NOT commonly associated with Mitral stenosis
NOT seen in primary tuberculosis Cavitation
NOT associated with primary tuberculosis Pleural effusion
Point of control in tuberculosis, the infection < 1% in 0-14 group of children
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TUBERCULOSIS 49
RESPIRATORY SYSTEM
Targets of STOP TB strategy Achieve a diagnosis rate > 70% and cure rate >85%,
Reduce prevalence to <150 per 1 lakh population,
Global incidence of TB disease less than or equal to 1
case per million population per year
If the objective of investigator is to assess the incidence Identify new converters to tuberculin test
of tuberculosis infection in a community, the most
appropriate methodology would be to
MDR TB is resistant to at least Isoniazid + Rifampicin
XDR- TB means resistance to Rifampicin, Isoniazid, Ciprofloxacin, Amikacin
Chemoprophylaxis is MOST impractical in control of Tuberculosis
MORPHOLOGY OF TUBERCULOSIS
Necrosis in Tuberculosis Caseative necrosis

Coagulative necrosis is NOT seen in Tuberculosis
Ghon focus Primary TB, peripheral transient hilar or paratracheal
lymphadenopathy
Ghon’s focus Subpleural caseous lesion just above or below
interlobar fissure
Ghon’s focus Sub Pleural in lower lobe
Ghon complex Ghon focus with or without pleural reaction, thickening and
regional lymphadenopathy
Ghon complex Parenchymal subpleural lesion, draining
lymphatics, enlarged casseous lymphnode
in pulmonary tuberculosis
Most common site of primary complex Middle zone of right lung
Seen in primary tuberculosis Ghon’s focus, Pleural effusion
Infraclavicular lesion of tuberculosis Assman focus
Assman focus Infraclavicular lesion of chronic
pulmonary tuberculosis
Secondary TB Puhl Lesion, Assman Focus
Most common site of isolated lesion of Apex of lung (Puhl lesion)
chronic TB
Simon focus Early hematogenous seedling in apex of
lung
Ranke complex Healed lesion in lung parenchyma, hilar
lymphnodes undergoing calcification
Rich focus is present in Meninges
Rich focus Tuberculous casseous foci in brain,
meninges and spinal cord
TUBERCULIN TEST
Most appropriate test to assess prevalence of TB Tuberculin test

infection in a community
Tuberculin test denotes Previous or present sensitivity to tubercle proteins
Tuberculin test Only tool available for estimation of prevalence of TB in
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TUBERCULOSIS 50
RESPIRATORY SYSTEM
a community, new cases occur commonly in patient

who are tuberculin reactors
Mantoux test A positive test does NOT indicate that the person is
suffering from disease
Mantoux test usually read after 48-72 hours
Tuberculin unit 1 unit of PPD RT3
Standard dose of tuberculin used in Mantoux test in 5 TU (TU = 0.1 ml)
India
Mantoux test is Type IV hypersensitivity
Tuberculin positive means Patient is infected with mycobacterium
Tuberculin test positivity is based on Induration
Tuberculin test positivity indicate Good cell mediated immunity
Suffering from active TB, has had tuberculosis infection, Positive mantoux test
has had BCG vaccine recently
True statement about tuberculin test More than 10 mm induration in 72 hours indicate
positive test
Tuberculin test May be negative in disseminated tuberculosis
False positive tuberculin Atypical mycobacteria
False negative tuberculin test seen in After 4-6 weeks of measles attack, immunodeficiency
state, miliary tuberculosis
Mantoux test in miliary tuberculosis NOT always positive
Local lesion in BCG is maximum in 28 days
BCG differs from Mantoux test by More sensitive and more specific
1 ml of expectoration contains what number of TB 10,000
bacilli in an active case of TB
Number of sputum positive cases per lakh population in 75
India
SPUTUM EXAMINATION
Induction of sputum Hypertonic saline

In TB, case is Sputum positive
WHO best criteria for TB diagnosis Sputum positive
A case of TB according to WHO is detected by Sputum examination
Most useful method of case finding in TB Sputum staining
Mycobacterium tuberculosis 20% Sulphuric acid
Sputum positive TB One out of 2 sample positive
Mycobacteria can be diagnosed on microscopy when 10,000 or more per ml
counts are
Tuberculosis >10^4 bacilli are required in sputum for detection
CULTURE OF MYCOBACTERIUM
Lowenstein Jenson media is used for cultivation of Mycobacterium tuberculosis

Selective media for TB bacilli Dorset media and LJ media
Mycobacterium tuberculosis LJ medium
Dorset egg culture medium Mycobacterium tuberculosis
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TUBERCULOSIS 51
RESPIRATORY SYSTEM
DIAGNOSIS OF TUBERCULOSIS
Sputum test and tuberculin test for Prevalence

New converters to tuberculin test Incidence
Investigations in a clinically susceptible case of Mantoux, Sputum AFB, PCR, Bactec
tuberculosis
Case finding in RNTCP based on Sputum microscopy
Ziehl Neelson technique Detection of mycobacteria
Antitubercular drug susceptibility done by Resistance ratio method, molecular method,
radiometric broth method
nd
Interferon gamma release assay (IGRAs) for diagnosis of 2 generation Quantiferon gold used ESAT-6 and CFp-
tuberculosis 10
Rapid examination of tubercle bacilli possible with Auramine rhodamine stain
Collection of urine sample of a patient of TB kidney is In early morning
done
MTP 64 antigen is associated with Tuberculosis
Quantiferon gold TB test is based on IFN gamma
Methods of antitubercular drug Resistance ratio method, radiometric
susceptibility broth method, molecular method
TREATMENT OF TUBERCULOSIS
Main aim of tuberculosis treatment Bacteriological cure

Indication of prophylactic ATT Immunosupression, Tuberculin positive adolescents,
Infant of infectious parents, recent tuberculosis in 3
years
Steroids along with antituberculosis therapy Tuberculosis of eye, Pericardial effusion, Tuberculous
meningitis, uretric obstruction in genitourinary
tuberculosis
Steroids are used in treatment of tuberculosis patient Lymphadenitis
with
Management of a newborn when mother has active BCG ,INH for 6 weeks, breast feeding
tuberculosis and is taking ATT
Born to mother with active tuberculosis Administer INH to baby, ATT to mother for 2 years, ask
mother to ensure proper disposal of sputum, continue
breast feeding
NOT an advice for TB mother in India Withhold breast holding
Anti TB action Amikacin, Gentamycin, Ciprofloxacin
Combination of antibiotics in tuberculosis is used to Delay development of resistance
MDT is used in TB because Reduced complication, Action at different level,
Decreased drug resistance
Multidrug resistance tuberculosis should be considered Contact with a known case of MDR TB, Clinical
in patients with deterioration, Sputum smear positive at 5 years of
treatment
Purpose of using ATT combination To reduce possibility of drug resistance
Treatment of choice for sputum positive pulmonary Start Cat I immediately
st
tuberculosis detected in 1 trimester of pregnancy
Cat I 3 months, discontinued for 1 month Do Sputum smear examination if negative continue Cat
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TUBERCULOSIS 52
RESPIRATORY SYSTEM
1
Color of category I TB Red
Color of category II TB Blue
Sputum negative not seriously ill Category II
Category II 3 (HRSZE)3 + (HRZE)3 + 5(HR)3
Drug used in DOTS category II Streptomycin
Category III TB Non DOTS TB
Category IV TB MDR TB
ATT having CSF penetration INH
Safest ATT in pregnancy INH
30 year female has sputum positive, her child 3 years INH 5 mg/kg for 6 months
old
Isoniazid and pyridoxine are given together To prevent Peripheral neuritis
INH metabolized in body by Acetylation
An otherwise well girl with strongly positive tuberculin Isoniazid for 1 year
test treated with
A lactating mother has sputum positive tuberculosis INH 5 mg/kg
and her neonate child is 3 months old. what is the
recommended chemoprophylaxis
NOT true about INH chemoprophylaxis Cheap
NOT a side effect of isoniazid Thrombocytopenia
Treatment of isoniazid poisoning Pyridoxine, Diazepam, Bicarbonate
Rifampicin is derived from Amycolatopsis rifamycinia (Streptomyces mediteranei)
Rifampicin resistance is associated with repoB gene
Does NOT need dose modification in renal failure Rifampicin
Penetrates into casseous necrosis in TB Rifampicin
Dose of rifampicin 10 mg/kg
Mechanism of action of rifampicin DNA dependent RNA polymerization inhibition
Antimicrobial do NOT need dose modification in renal Rifampicin
failure
Drug inhibiting DNA dependent RNA polymerase in Rifampicin
mycobacteria
Drug of choice for Mycobacterium bovis Rifampicin
DNA dependent RNA synthesis inhibited by Rifampcin
Most effective ATT against slow multiplying intracellular Rifampicin
mycobacteria
ATT safely used in renal failure Rifampicin
Most effective drug against extracellular mycobacteria Rifampicin
Daily dose of rifampicin does NOT cause Flu like syndrome
NOT true about rifampicin Flu like syndrome is usually seen with rifampicin taken
on DAILY basis
Rifapentin, Rifabutin exhibit cross resistance with Rifampicin
ATT not to be given with protease inhibitors Rifampicin
Flu like syndrome is associated with Rifampicin
ATT causing orange colored urine Rifampicin
Mechanism of resistance in rifampicin Mutation in beta subunit of RNA polymerase
ATT associated with arthralgia Pyrizinamide
X ray picture of TB given, he developed Jaundice after Pyrizinamide
ATT, Which drug should NOT be given
ATT causing hyperuricemia Pyrazinamide
Side effects of Pyrizinamide Hyperuricemia, arthralgia
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SARCOIDOSIS 53
RESPIRATORY SYSTEM
Pyrizinamide resistance is associated with pncA gene

ATT safer in hepatitis Ethambutol
Bacteriostatic antitubercular drug Ethambutol
Need dose reduction even in mild renal failure Ethambutol
Retrobulbar neuritis Ethambutol
ATT causing Red green blindness Ethambutol
Ethambutol accumulates in Renal failure
ATT associated with visual deterioration Ethambutol
Ethambutol toxicity Decreased visual acuity, color blindness for green,
central scotoma
Hepatotoxicity is NOT seen with Ethambutol
Antitubercular drug contraindicated in pregnancy Streptomycin
ATT NOT causing blood brain barrier Streptomycin
Streptomycin resistance is associated with gidB
Cycloserine is an analogue of Aminoacid (d-alanine)
Toxicity of cycloserine enhanced by INH, amphotericin B, simvastatin, alcohol
Neuropsychiatric manifestation Cycloserine
ATT causing psychosis Cycloserine
ATT causing transient memory loss Isoniazid
NOT a hepatotoxic Cycloserine
Cross resistance of isoniazid seen with Ethionamide
ATT causing hypothyroidism Ethionamide
Anti tubercular drug contraindicated in Thiacetazone
HIV
Drug resistance in tuberculosis is due to Mutation
Enzymes in INH resistant tuberculosis Catalase, peroxidase
Clarithromycin resistance is associated with ermB
Treatment of latent tuberculosis in adults (LTBI) Isoniazid for 9 months or Rifampicin for 4 months
Resistance to all first line drugs 1 injectable (amikacin/kanamycin/capreomycin) plus 3 of
these 4 (ethionamide, cycloserine, Quinidine, PAS)
Drug NOT used in treating MDR TB Isoniazid
NOT a treatment of MDR TB Tobramycin
NOT an ATT 5 flucytosine
SARCOIDOSIS
Besbuer boeck scahaumann disease is also called as Sarcoidosis

Infective agents associated with Atypical mycobacteria,
sarcoidosis propionibacterium acne
Diseases associated with bimodal Sarcoidosis, hodgkin’s lymphoma,
distribution Goodpasture syndrome
Smoking is NOT associated with Sarcoidosis
Scadding staging for Sarcoidosis
HLA associated with sarcoidosis HLA DR B
MC cranial nerve involved in sarcoidosis Facial nerve
Granuloma in sarcoidosis is called Hard sore
Uveoparotitis is a manifestation of Sarcoidosis
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BRONCHOGENIC TUMORS 54
RESPIRATORY SYSTEM
Cutaneous red brown lesion Sarcoidosis

Sarcoidosis is associated with Lupus pernio
Potato nose Sarcoidosis
Pseudotumor of parotid is associated with Sarcoidosis
Sarcoidosis associated with Hyperkalemia
Sarcoidosis is associated with Band keratopathy
Sarcoidosis Bilateral hilar lymphadenopathy with perihilar
calcification
Young lady bilateral nodular lesion on skin, bilateral Non caseating granuloma
hilar lymphadenopathy, mantoux 5mm
Bilateral hilar lymphadenopathy with non caseating Sarcoidosis
granuloma
Non Caseating Granuloma Sarcoidosis
Epithelioid cells without caseation Sarcoidosis
Refractile bodies Sarcoidosis
Schaumann asteroid bodies in Sarcoidosis, Asbestosis, Silicosis
Mechanism of Hypercalcemia in Sarcoidosis Vitamin D containing vascular macrophages
Hepatic manifestation of sarcoidosis Elevated alkaline phosphatase
MC cause of death in sarcoidosis Cor pulmonale
Sarcoidosis Spontaneous remission is usual, Tuberculin test is
negative
Lofgren syndrome Acute form of sarcoidosis associated with good prognosis
Acute pulmonary sarcoidosis LEAST likely associated Pleural effusion
with
NOT true about sarcoidosis Often cavitate
NOT a feature of sarcoidosis Urticaria pigmentosa
Sarcoidosis does NOT involve Brain
Kveim test for Sarcoidosis
Investigations used for sarcoidosis Serum ACE level, CECT of chest, Gallium scan
Raised serum ACE Sarcoidosis, silicosis, berylliosis
Bronchoalveolar lavage in sarcoidosis CD4:CD8 > 3.5
Signs in sarcoidosis Panda sign in gallium scan, lambda sign
Interferon alpha is contraindicated in Sarcoidosis with hepatitis C infection
BRONCHOGENIC TUMORS
GENERAL FEATURES OF BROCHOGENIC TUMOR
Broncholithiasis Calcified lymph nodes eroding into bronchus

Neuroendocrine hyerplasia in scarred lung Tumorlet
Lung carcinoma and occupation Risk is increased, takes long duration to develop, less
time to develop as compared to normal population
Gas associated with lung cancer Radon
In a population of 1000 beta carotene was give to 6000, Beta carotene and lung cancer has no relation to each
3 out of first group has got lung cancer. 2 out of other other
group also got lung cancer
NOT associated with lung cancer Mercury
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RESPIRATORY SYSTEM
Commonest intrabronchial cause of hemoptysis Carcinoma lung

MC cancer affecting both male and female of the world Lung cancer
MC Presentation of Ca Lung Cough
Features of bronchoalveolar carcinoma Hemoptysis, collapse, effusion
Malignant mass in hilum of left lung growing anteriorly Phrenic nerve
towards principal bronchus will compress
Left recurrent laryngeal nerve is involved in Bronchogenic carcinoma
MC cause of Left Recurrent Laryngeal Nerve Palsy Ca Bronchus
Hoarseness secondary to bronchogenic tumor due to Left recurrent laryngeal nerve
MC site of metastasis of carcinoma bronchus Liver and bones
Most common site of primary in case of secondaries to Lung
adrenals
Central location Squamous cell carcinoma, Small cell carcinoma
Non metastatic manifestation of bronchogenic Adrenal insuffiency
carcinoma
Hormone producing bronchogenic carcinoma manifests Hormonal changes earlier than other
Hypervolemia in Ca Lung is due to SIADH
Polyuria, pain abdomen, nausea, vomiting, altered Hypercalcemia
sensorium known to have bronchogenic carcinoma.
electrolyte abnormality
Paraneoplastic syndrome in Bronchogenic carcinoma Myasthenia gravis, Hyperparathyroidism, Hypertrophic
Pulmonary Osteoarthropathy
Paraneoplastic syndrome NOT seen in carcinoma lung Hypoglycemia
Calcification inside coin shadow on chest X-ray rules out Bronchogenic carcinoma
diagnosis of
Non caseating granuloma NOT seen in Metastatic ca lung
NOT a clinical feature of bronchogenic carcinoma Gastroparesis due to vagal involvement
Least amenable to screening Lung carcinoma
65 year old smoker, hoarseness, hemoptysis, hard Undertake open biopsy of neck lump
painless lump in left supraclavicular fossa
Autopsy of lung of old man shows, bronchi lined by Dysplasia
stratified squamous epithelium
Lung malignancy associated with Large Hilar Lymph Non small cell lung cancer
nodes & Mediastinal Lymphnodes
SMALL CELL CARCINOMA OF LUNG
MC Bronchogenic Carcinoma causing Paraneoplastic Small Cell Carcinoma [ACTH, AVP(Vasopressin),

Syndrome Calcitonin, ANF, Gastrin releasing peptide]
MC Bronchogenic Carcinoma causing Hypokalemia Small cell Carcinoma (ACTH)
In a chronic smoker, a highly malignant aggressive and Small cell carcinoma
metastatic lung carcinoma
Type of lung carcinoma producing SVC syndrome Small cell carcinoma
Clubbing least common in Small cell carcinoma
Small cell carcinoma Associated with paraneoplastic syndrome, Cause SVC
obstruction, Chemosensitive, Commonly metastasize to
brain
Hypersecretory granules are associated with Small cell carcinoma
Carcinoma lung with poor prognosis Small cell carcinoma
60 year old patient, male, presented to emergency with SVC obstruction
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RESPIRATORY SYSTEM
breathlessness, facial swelling, dilated veins on chest

wall
Tumor commonly associated with SVC syndrome Small cell carcinoma
Chronic smoker, mild hemoptysis, hypertension and Ectopic ACTH secreting tumor
obesity. Raised ACTH not suppressed by
dexamethasone. Cause for cushing’s syndrome in
patient
In small cell carcinoma of lung, blood vessels in necrotic Azzopardi effect
area may show smudged hematoxophilic material in
their walls which represents DNA released from tumor
cells
Feature of small cell cancer Greater response to chemotherapy
Carcinoma most frequently metastasize to brain Small cell carcinoma
Highly malignant aggressive metastatic lung carcinoma Small cell carcinoma
Hormones increased in small cell carcinoma of lung ACTH,ANF,AVP
NOT elaborated by small cell carcinoma Noradrenaline
Hormone level NOT raised in small cell carcinoma lung Growth hormone
Oat cell carcinoma Variant of Small cell carcinoma
ACTH producing lung carcinoma Oat cell carcinoma
Oat cell variety of lung carcinoma associated with Hilar lymphadenopathy
Small cell lung carcinoma have a Leptomeninges
recognized tendency to spread to
NON SMALL CELL CARCINOMA OF LUNGS
Non small cell carcinoma Squamous cell carcinoma is MC NSCCL among Asian
population, Contralateral mediastinal nodes are a
contraindication to surgical resection, Single agent
chemotherapy is preferred for patient >70 years with
advanced tumor, Gefitinib is most effective for FEMALE
WHO NEVER SMOKED with adenocarcinoma on history
60 year man, non productive cough and hemoptysis for Non small cell carcinoma
4 weeks. grade III clubbing and a lesion in apical lobe on
X ray
Tumor NOT associated with organism Non small cell carcinoma of lung
MC lung cancer in non smokers Adenocarcinoma
MC Type of Bronchogenic Carcinoma, MC Type of Adenocarcinoma
Bronchogenic carcinoma in Young Patients, MC Type of
Bronchogenic carcinoma in Females
Scar in lung tissue can transform to Adenocarcinoma
Adenocarcinoma of lung Peripheral location, Common in females, Common in
non smokers, Lung to lung metastasis
Lung to lung metastasis in Adenocarcinoma of lung
Tumor marker in adenocarcinoma of lung Thyroid transcription factor
MC Bronchogenic Carcinoma causing Hypercalcemia Squamous cell carcinoma (PTH)
MC Type of Bronchogenic cancer in Smoker, MC type of Squamous cell carcinoma
bronchogenic cancer in India
Cavity formation in bronchogenic carcinoma Squamous cell carcinoma
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RESPIRATORY SYSTEM
MANAGEMENT OF BRONCHOGENIC TUMOR
Marker differentiating primary lung Thyroid transcription factor 1

cancer from colonic metastasis
HRCT is ideal for evaluation of Bronchoalveolar cancer
Chronic smoker, hemoptysis, X ray normal. next Bronchoscopy
investigation
Suspected of bronchogenic carcinoma, TB ruled out, Bronchoscopy and biopsy
next investigation
Cavitatory lesion in right upper lobe of lung. best Bronchoscopy, lavage and brushing
investigation
Marker for small cell carcinoma lung Chromogranin and synaptophysin
Salt pepper chromatin Squamous cell carcinoma
Ground glass appearance in CT Bronchoalveolar carcinoma (Adenocarcinoma)
Serum ACE NOT raised in Bronchogenic carcinoma
Important first line drug for non small cell lung carcinoma Cisplatin
Only FDA approved second line drug for squamous cell Topotecan
carcinoma
Erlotinib Tyrosine kinase inhibitor, rashes may occur, non small
cell lung cancer
Vinorelbine is used in treatment of Non small cell lung cancer
New anti sense drug to protein C used in Affinitac
management of non small cell lung cancer
H/O Ca lung. drug NOT given Bleomycin
In video assisted thoracoscopic surgery for better Collapse of ipsilateral lung
vision, the space in operative field is created by
Treatment of postoperative lung collapse Endoscopic suction
Contraindication for surgical resection in ca lung Malignant pleural effusion
60 year, ca right lung tumor 5*5 cm in upper lobe and Surgery
other 2*2 cm in middle lobe
First step while doing pneumonectomy Ligate pulmonary artery
Most important consideration in patient with Elevated pulmonary artery pressure
borderline pulmonary function requiring lung resection
Adenocarcinoma of lung with no metastasis Surgery
Carcinoma right lung, 5*5 cm tumor in upper lobe, Surgery
another tumor 2*2 cm in middle lobe. Treatment is
Surgical resection is not recommended by Small cell lung carcinoma
BRONCHIAL ADENOMA AND BRONCHIAL CYST
Bronchial adenoma commonly presents as Recurrent hemoptysis

Blood stained sputum only symptom in Adenoma bronchus
MC site of bronchial cyst Mediastinal
Extralobal bronchogenic cyst do NOT communicate with Bronchus
NOT true about bronchial cyst 50-70% occur in lung, Commonly infected, Multilocular
NOT true about bronchial cyst Multilocular
Commonest benign tumor of lung Hamartoma
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CYSTIC FIBROSIS 58
RESPIRATORY SYSTEM
CYSTIC FIBROSIS
Chromosome associated with cystic fibrosis Chromosome 7

MC mutation in Cystic Fibrosis Mutation of Phenylalanine at Position 1> 508
Cystic fibrosis autosomal recessive, normal couple has ¼
one daughter affected. chance of her sibling being
affected by the disease
For a husband and wife, the first child was diagnosed to 0
have cystic fibrosis. percentage of chances for the
second child be affected
MC type of mutation in cystic fibrosis Class 3 mutation
Class 1 Premature stop codon mutation
Class 4 mutation is associated with Mild pancreatic insufficiency
Delta 508 mutation in cystic fibrosis Deletion
MC cause of Infection in Cystic Fibrosis in adolescents Pseudomonas aeroginosa
and adults
MC cause of Infection in Cystic fibrosis in Children Staphylococcus aureus
nd
MC organism in Cystic fibrosis Pseudomonas, 2 Staphylococcus
Meconium ileus is seen in Cystic fibrosis
Features of cystic fibrosis Lungs normal at birth
Gastrointestinal features of cystic fibrosis Distal intestinal obstruction syndrome
System least affected in cystic fibrosis Endocrine
NOT seen in patient with cystic fibrosis Metabolic acidosis
NOT true about cystic fibrosis Abnormality is CFTR will lead to defective calcium
transport
Earliest X ray change in cystic fibrosis Hyperinflation
Most sensitive investigation for cystic fibrosis Sweat chloride
Electrolytes are increased in Cystic fibrosis
Sweat chloride 40-60 on two occasion performed next Abnormal nasal potential difference
to support diagnosis of cystic fibrosis
Diagnostic investigation of Cystic fibrosis Sweat chloride > 70 mEq/L
Pilocarpine iontophoresis in cystic fibrosis Sweat chloride > 70 mEq/L, Na < 70 mEq/L
Presence of immunoreactive trypsinogen in blood spots Cystic fibrosis
in newborn is suggestive of
Drug for cystic fibrosis Denufosol
KARTAGENER SYNDROME
Kartagener Syndrome Bronchiectasis, Situs Inversus, Sinusitis, Dextrocardia,

Infertility
Kartagener syndrome is due to mutation Axonemal dynein
in
Situs inversus is associated with Kartagener syndrome
Sinobronchial infection seen with Kartagener syndrome
Decreased motility of fallopian tube Kartagener’s syndrome
NOT included in Kartagener syndrome Lobular emphysema, mental retardation, cystic
retardation
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VENTILATOR 59
RESPIRATORY SYSTEM
NOT a feature of Kartagener syndrome Dysphagia
VENTILATOR
Ventilation Invasive and non invasive

Factor determining end of inspiration Volume
MC mode of ventilation Assisted
Intermittent mandatory ventilation Intermittent spontaneous breath
Inverse ratio ventilation is used in Severe hypoxemic respiratory failure
CPAP Given prophylactically in all preterm with respiratory
distress, given in infants less than 28 weeks, improves
oxygenation and improves lung compliance
CPAP Initiate as early in preterm with respiratory distress,
initiate with <50-60 % FiO2, improved lung compliance
and oxygenation
IPPV can cause Barotrauma
NOT a complication of IPPV Pleural effusion
NOT true about PEEP Decreased ICT
NOT a complication of PEEP Emphysema
Inspiratory flow rate in volume cycled ventilation 60-100 L/min
Severe head injury mode of ventilation CMV
NOT seen in controlled ventilation Cardiac tamponade
Mean Airway pressure increased by Increasing PIP
Modes used for weaning from ventilator Pressure Support, CPAP,T piece trial
Modes used for weaning off patients from mechanical SIMV, PSV, ACV
ventilation
Mode NOT used for weaning off patients from Controlled mechanical ventilation
mechanical ventilation
MC cause of hypoxia during one lung ventilation Increased shunt fraction
Ciprofloxacin is ineffective in peritonitis of continuous High MIC for Coagulase negative Staphylococcus
ambulatory peritoneal dialysis because of
A boy was operated for ASD and was on Mechanical Respiratory depression
Ventilator. Opioids and benzodiazepines were given for
analgesia and sedation. Number of cycles was reduced
from 20 to 10 /minute when the PCo2 was 95 mm of hg
, Po2 120mm hg , ph 7.13 and there was no
spontaneous breathing. Breath sounds were decreased
in the left infrascapular region. The probable cause for
his acidosis
Features of successful weaning from paO2 of 70 mm Hg, FiO2 of 0.35 or less,
ventilation alveolar arterial gradient < 350 mm Hg,
ratio of PaO2 to FiO2 > 200, PaCO2 30 mm
Hg to 55 mm Hg, vital capacity of 10 – 15
ml/kg, tidal volume of over 5 ml/kg,
respiratory rate less than 30 breaths per
minute
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Respiratory System

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RESPIRATORY

RESPIRATORY FAILURE AND PULMONARY DISEASE ................................................................................................... 24

MORPHOLOGY OF PNEUMONIA ............................................................................................................................. 42

KEY TO THIS DOCUMENT

Text in normal font – Must read point.

Text in bold font – Point from Harrison’s

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DEVELOPMENT OF RESPIRATORY SYSTEM

Fetal respiratory movements 12 weeks

ANATOMY OF RESPIRATORY SYSTEM

Respiratory cilia 9 microtubular doublet with central

Pulmonary plexus Cell bodies of post ganglionic

PHYSIOLOGY OF RESPIRATORY SYSTEM

GENERAL FEATURES OF RESPIRATORY PHYSIOLOGY

Normally lungs are kept dry by Osmotic pressure in interstitium

Respiration stops in last stage of expiration, in forced Dynamic compression of airway

INSPIRATION AND EXPIRATION

Lattisimus dorsi used in Forced EXPIRATION

Surfactant is produced by Type II pneumocytes

Oxygen cascade Oxygen cascade describes the process of

Po2 in atmospheric air

VENTILATION PERFUSION RATIO AND COMPLIANCE

Normal respiratory system compliance 0.2 L/cm H2O

HYPERCARBIA AND ALVEOLAR HYPOVENTILATION

Gradient of alvelolar arterial oxygen tension in Normal

Hyperventilation caused by Decreased pH in CSF, decreased plasma HCO3,

HIGH OXYGEN TENSION

Hyperbaric oxygen is dangerous because it Is toxic to tissues

O2 content of arterial blood 19.4 ml/100 ml

Hemoproteins Cytochrome c, Cytochrome 450, Myoglobin,

Buffer NOT involved in non rapid achievement of Renal Hemoglobin

OXYHEMOGLOBIN DISSOCIATION CURVE

Amount of oxygen consumed per minute 250 ml

Pacemaker of respiration Pre Botzinger complex

Inhibition of Pneumotaxic centre causes Prolonged Inspiratory spasm

LUNG VOLUMES, CAPACITIES AND ALVEOLAR VENTILATION

PFT Total lung volume increases in emphysema, Compliance

During acclimatization Increase in minute ventilation, increased in sensitivity of

Acute mountain sickness is associated with Sleep desaturation

SIGNS AND SYMPTOMS OF RESPIRATORY SYSTEM

GENERAL SIGNS AND SYMPTOMS OF RESPIRATORY SYSTEM

Hypoxemia Hypoventilation, Decreased FiO2, Myasthenia gravis,

To visualize vascular sling causing tracheal or external MRI

MC cause of Hemoptysis Bronchitis>Bronchogenic carcinoma

Central cyanosis Decreased arterial O2 saturation, hemoglobin abnormalities

Central cyanosis is seen if O2 concentration <85%

Earliest evidence of clubbing Fluctuation

Pancoast triad Shoulder or arm pain, atrophy of hand

Cavitating lesions of lung Caplan syndrome, Wegener granulomatosis, Squamous

45 year old coalmine worker, Cutaneous nodules, joint Caplan syndrome

Acute lung injury PaO2/FiO2 less than or equal to 300 mm Hg

Acute lung injury Aspiration, Toxic gas inhalation, Lung contusion

extensive hemorrhage with red appearance. lesion has

IVC filter NOT used for Negligible size thrombi

Normal pulmonary artery pressure at rest Systolic 25 mm Hg, diastolic 10 mm Hg

PULMONARY VENOUS HYPERTENSION

Perihilar fluffy opacities of chest wall, Peribronchial Pulmonary venous hypertension

MC cause of Chronic Cor Pulmonale COPD

RESPIRATORY FAILURE AND PULMONARY DISEASE

MC cause of type I respiratory failure Chronic bronchitis with emphysema

Chronic respiratory failure eventually Pulmonary hypertension, right sided

MC organism causing Emphysema in children under 2 Staphylococcus

emphysematous lesion with bullous lesion

OBSTRUCTIVE AND RESTRICTIVE LUNG DISEASE